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PubMed2003

Should a positive surgical margin following radical prostatectomy be pathological stage T2 or T3? Results from the SEARCH database.

PURPOSE: The finding of a positive surgical margin associated with extracapsular extension at radical prostatectomy is a poor prognostic factor. However, whether a positive surgical margin with no documented extracapsular extension portends a similarly poor prognosis is unclear. We examined the significance of the pathological features of positive surgical margin and extracapsular extension for predicting biochemical failure following radical prostatectomy. MATERIALS AND METHODS: We examined data on 1,621 men from the SEARCH Database of patients treated with radical prostatectomy without lymph node metastasis. Patients were separated into 5 groups based on the pathological findings of positive surgical margin, extracapsular extension, and/or seminal vesicle invasion. Preoperative clinical variables were compared across the groups and the groups were compared for time to biochemical recurrence using Cox proportional hazards analysis. RESULTS: Men with seminal vesicle invasion had the highest prostate specific antigen (PSA) recurrence rates, while men with a negative surgical margin and no extracapsular extension had the lowest PSA recurrence rates. There were no differences in PSA failure rates between men with a positive surgical margin and no extracapsular extension versus men with a negative surgical margin and extracapsular extension versus men with extracapsular extension and a positive surgical margin. In this subset of patients with a positive surgical margin and/or extracapsular extension but no seminal vesicle invasion only serum PSA was a significant independent predictor of biochemical recurrence. CONCLUSIONS: Men with a positive surgical margin but no extracapsular extension had PSA recurrence rates similar to those in men with extracapsular extension with or without positive margins. Men with extracapsular extension had similar biochemical recurrence rates whether the surgical margin was positive or negative. If confirmed at other institutions, consideration should be given to modifying the current TNM staging system to reflect these findings.

Humans↗
PubMed2003

Is there an optimal time for intracavernous prostaglandin E1 rehabilitation following nonnerve sparing radical prostatectomy? Results from a hemodynamic prospective study.

PURPOSE: Previous studies have shown that early intracavernous prostaglandin E1 injection may reduce significantly the incidence of veno-occlusive dysfunction before spontaneous erections recover after nerve sparing radical prostatectomy. We identify the more convenient postoperative timing for successful intracavernous injection rehabilitation in a series of patients who underwent nonnerve sparing radical prostatectomy. MATERIALS AND METHODS: A total of 73 patients with a normal preoperative International Index of Erectile Function score were randomly allocated to undergo dynamic color Doppler ultrasound study 20 mg. prostaglandin E1 at 1, 2 to 3, 4 to 6 and 7 to 12 months postoperatively, respectively. In all cases the peak systolic velocity, end diastolic velocity and resistance index were evaluated at 5, 10 and 20 minutes after injection. RESULTS: Of the patients 36 received the intracavernous injection within the first 3 months (group 1) and 37 received it at 4 to 12 months (group 2). A significantly higher proportion of group 1 patients had grade 3 erection compared with group 2. Peak systolic velocity less than 30 cm. per second in at least 1 cavernosal artery was recorded in 22.2% of group 1 patients and 51.3% of group 2 (p >0.05). CONCLUSIONS: Intracavernous injections after nonnerve sparing radical prostatectomy produce valid erectile responses in a significantly higher proportion of patients when started within month 3 after the operation. Injection given in postoperative month 1 gives the best response rate but with significant complications and poor patient compliance. Arteriogenic and venogenic factors seem to be involved with failure.

Aged↗
PubMed2003

Positive surgical margins in laparoscopic radical prostatectomy: the impact of apical dissection, bladder neck remodeling and nerve preservation.

PURPOSE: We assess the incidence and location of positive surgical margins in a consecutive series of patients who underwent laparoscopic radical prostatectomy. MATERIALS AND METHODS: Between May 1998 and September 2001, 235 men underwent laparoscopic radical prostatectomy at our institution. During this period modifications were made in the technique. We stopped preserving the puboprostatic ligaments during 1999 and stopped preserving the bladder neck during 2000. We compared the incidence of apical and bladder neck margins before and after these changes in surgical technique. Nerve sparing status was documented by the surgeon at the end of the operation and its effect on the incidence of lateral positive margins was evaluated. To concentrate on the surgically induced margins this study focused on pT2 cases. RESULTS: There were 169 pT2 cases and 32 (18.9%) positive margin locations. A constant decrease was noted in the overall incidence of positive margins but, while apical margins were the most abundant in 1998, posterolateral margins were most abundant in 2001. Avoiding bladder neck preservation eliminated positive bladder neck margins in 2001. The overall incidence of positive lateral surgical margins in pT2 cases treated with a nerve sparing procedure was 8.4%. CONCLUSIONS: The experience gained in this procedure led to a decrease in the incidence of positive margins. Wide resection of the bladder neck and cutting the puboprostatic ligaments decreased bladder neck and apical positive margins. Nerve preservation did not increase the incidence of positive margins. These technical modifications may improve the outcome of laparoscopic radical prostatectomy.

Aged↗
PubMed2003

Early catheter removal after radical retropubic prostatectomy: long-term followup.

PURPOSE: We examine the complication and continence rates with early catheter removal (day 3 or 4) after radical retropubic prostatectomy. MATERIALS AND METHODS: A total of 365 patients with localized prostate cancer underwent radical retropubic prostatectomy at Indiana University Hospital with planned urethral catheter removal before discharge home. Low pressure cystograms were performed on postoperative day 3 or 4 to determine if catheter removal was possible. A subset of patients were analyzed using a validated prostate cancer specific questionnaire (University of California, Los Angeles Prostate Cancer Symptom Index) to determine quality of life outcomes. RESULTS: The catheter was removed on postoperative day 3 or 4 in 263 patients (72%). The reasons for leaving the catheter indwelling were significant leak on cystogram or excessive suprapubic drainage (21%), extensive bladder neck reconstruction (1%) and prolonged hospitalization because of an ileus or other complicating factor (6%). Thirteen patients (3.6%) were either unable to void after catheter removal or presented with retention (not associated with hematuria or clots) after hospital discharge, requiring reinsertion of the Foley catheter. A total of 41 patients (11%) had either an early or late complication (excluding incontinence). There were 3 complications (0.8%) that were considered major because they were potentially life threatening or required a return to the operating room. A pelvic abscess developed in 2 patients and a lymphocele in 1, which required percutaneous drainage. After at least 6 months (mean 20.9 months) 140 patients (89.2%) and 14 (8.9%) reported excellent and good continence, respectively. The patient questionnaire demonstrated bother scores to be minimal to no bother for 95% to 98% of patients at 6 and 12 months. CONCLUSIONS: This study confirms that it is safe to remove catheters in most patients 3 to 4 days after prostatectomy if a cystogram demonstrates no extravasation. Complication rates and continence rates with this approach compare favorably with series in which catheters are left indwelling for longer periods.

Device Removal↗
PubMed2003

Radical prostatectomy nomograms in black American men: accuracy and applicability.

PURPOSE: Nomograms have been developed to allow the prediction of disease recurrence based on clinical and pathological parameters in patients with clinically localized prostate cancer. However, they have been constructed using predominantly white American male (CAM) cohorts. We have previously shown that black American males (AAMs) have worse disease-free survival after radical prostatectomy after controlling for known prognostic factors. We tested the accuracy of prognostic nomograms in a population of AAMs with prostate cancer treated with radical prostatectomy. MATERIALS AND METHODS: We tested the performance of published preoperative and postoperative prognostic nomograms in a cohort of patients treated with radical prostatectomy as monotherapy for localized prostate cancer at Wayne State University in the prostate specific antigen era. Predictions made with the nomogram were stratified by race and compared with actual outcomes. The summary statistic used to evaluate the nomogram was the concordance index. A value of 0.5 indicates no predictive discrimination, whereas a value of 1.0 indicates perfect discrimination. RESULTS: A total of 1,043 patients, including 331 AAMs (32%) and 712 CAMs (68%), comprised the study cohort. Treatment failure was defined as increasing prostate specific antigen, which occurred in 193 patients (18.5%). The preoperative concordance index for CAMs and AAMs was 0.78 and 0.74, respectively (p = 0.8). The postoperative index was 0.85 and 0.83, respectively (p = 0.9). CONCLUSIONS: Preoperative and postoperative nomograms can be applied accurately to an individual regardless of race.

Black People↗
PubMed2003

Radical endoscopic assisted perineal prostatectomy.

PURPOSE: During radical perineal prostatectomy transection of the bladder neck and dissection of the seminal vesicles under direct vision can be difficult. We describe a technique of radical endoscopic assisted perineal prostatectomy that facilitates dissection of these structures. MATERIALS AND METHODS: Cadaveric dissections were performed in 4 individuals to develop and assess the technique. It was subsequently applied to a 64-year-old male with clinically localized prostate cancer (Gleason grade 3+3). Management of the bladder neck and seminal vesicles was performed with a bipolar transurethral resectoscope. The remainder of the procedure was performed via a traditional subsphincteric perineal approach with the patient in the standard dorsal lithotomy position. RESULTS: The bladder neck and seminal vesicles were successfully dissected in 55 minutes. Total operative time was 3 hours. Estimated blood loss was 500 cc. The patient was discharged home the morning of postoperative day 1 and the catheter was removed in the clinic on postoperative day 7. The final pathology report showed organ confined prostate cancer (Gleason 3+3). CONCLUSIONS: Radical endoscopic assisted perineal prostatectomy allows precise dissection of the bladder neck and seminal vesicles under direct vision. Accomplishing this dissection as the initial step of the procedure mobilizes the prostate, facilitating excision, and obviates the need for the extreme lithotomy position.

Endoscopy↗
PubMed2003

Health related quality of life significance of single pad urinary incontinence following radical prostatectomy.

PURPOSE: Continence outcomes after radical prostatectomy are frequently reported as the proportion of men using 1 urinary pad or less daily. We postulated that under appreciated health related quality of life (HRQOL) differences may exist between patients requiring 1 pad daily and those who do not require pads. MATERIALS AND METHODS: A total of 168 patients who underwent radical prostatectomy performed by a single surgeon in a 2-year period were surveyed at a mean of 75 +/- 30 weeks postoperatively using the urinary function and bother scales of the University of California-Los Angeles Prostate Cancer Index (PCI), the American Urological Association symptom index and a question assessing satisfaction. To establish patient groups the levels of the PCI question assessing pad use were redefined to 0, 1, or 2 or greater pads daily. The remaining 4 urinary function questions were used to calculate the summary function score. RESULTS: Of the patients 146 (86.9%) reported no pad use and 20 (11.9%) used 1 pad daily. The mean function score +/-SD was 81.7 +/- 19.5 and 51.5 +/- 26.5 for the no and 1 pad groups, respectively (p <0.0001). The mean bother score was 86.8 +/- 18.8 and 54.2 +/- 30.0 (p <0.0001). There were sharp differences between the 2 groups for each of the individual PCI questions and for the satisfaction question but no differences in American Urological Association symptom index scores. CONCLUSIONS: We noted significant differences in urinary HRQOL between patients who do not require urinary pads after surgery and those who use a single pad daily across several domains of urinary function and bother. We believe that these findings underscore the need for more comprehensive HRQOL assessment in urinary outcome assessment after prostatectomy.

Humans↗
PubMed2003

Neoadjuvant hormone therapy before salvage radiotherapy for an increasing post-radical prostatectomy serum prostate specific antigen level.

PURPOSE: We retrospectively evaluated the benefit of neoadjuvant androgen deprivation therapy administered before salvage external beam radiation treatment in patients with biochemical failure following retropubic radical prostatectomy (RRP). MATERIALS AND METHODS: A total of 81 patients were treated with neoadjuvant androgen deprivation therapy before salvage external beam radiation treatment because of an increased prostate specific antigen (PSA) level following RRP. Preoperative, pathological, postoperative, and pre-salvage treatment parameters and radiation therapy dosage were examined for influence on outcome. Biochemical failures after RRP or salvage external beam radiation treatment were defined as a PSA greater than 0.3 ng/ml on 2 consecutive measurements. Median radiation dose delivered was 60 Gy. Neoadjuvant androgen deprivation therapy consisted of a 3 month injection of a luteinizing hormone releasing hormone analogue. Median followup was 38 months (range 12 to 102) after completion of external beam radiation treatment and 91 months (range 20 to 163) after radical prostatectomy. RESULTS: The actuarial free biochemical failure rates at 3 and 5 years were 75% and 50%, respectively. Two patients (2%) died of prostate cancer. Significant predictors of response to salvage external beam radiation treatment on a univariate analysis were a pre-radiation serum PSA less than 1 ng/ml and a pathological Gleason score less than 7. However, only pre-radiation PSA remained statistically significant on a multivariable analysis. CONCLUSIONS: External beam radiation with neoadjuvant androgen deprivation therapy is a viable option for patients with an increasing post-prostatectomy serum PSA. The most powerful predictor of biochemical failure was pre-radiation serum PSA.

Aged↗
PubMed2003

Pelvic floor exercises, electrical stimulation and biofeedback after radical prostatectomy: results of a prospective randomized trial.

PURPOSE: We assessed the effect of pelvic muscle exercises (PMEs), electrical stimulation (ES) and biofeedback (BFB) on urinary incontinence after radical retropubic prostatectomy. MATERIALS AND METHODS: We randomized 139 patients who underwent radical retropubic prostatectomy into 3 groups. Group 1 received instructions about postoperative PMEs. Group 2 received the same instructions and ES for 15 minutes twice daily. Patients in group 3 were also treated with BFB for 15 minutes twice daily. Treatment was started immediately after catheter removal and performed for 3 months. The outcome was assessed using the 20-minute pad test and a urine symptom inventory. Results at baseline, and 3 and 12 months postoperatively were available for 139, 120 and 128 (questionnaire), and 116, 79 and 124 (pad test) patients, respectively. RESULTS: An overall subjective spontaneous continence rate (questionnaire) 1 day after catheter removal of 21.4% increased within the first 3 months up to 59.2%. There was no significant difference among the 3 groups. The continence rate increased from 3 to 12 months postoperatively from 59.2% to 85.9%. An overall objective spontaneous continence rate (pad test) 1 day after catheter removal of 32.9% increased within the first 3 months up to 65% and up to 83% after 12 months without any significant difference in all 3 groups. CONCLUSIONS: A treatment program of ES and BFB enhanced PMEs did not affect continence after radical prostatectomy after 3 or 12 months. Up to 711 euro can be saved per patient.

Aged↗
PubMed2003

Initial results of salvage laparoscopic radical prostatectomy after radiation failure.

PURPOSE: We evaluated the feasibility of laparoscopic radical prostatectomy for recurrence after irradiation. MATERIALS AND METHODS: Since 2000, 7 patients with biological failure after irradiation (5 external beam radiation and 2 brachytherapy), and no metastasis on computerized tomography and bone scan underwent a transperitoneal laparoscopic radical prostatectomy according to the Montsouris technique. The left index finger was placed in the rectum to control the prostatorectal dissection. We call this procedure "finger assisted laparoscopy." RESULTS: Average operating time was 190 minutes (range 170 to 210), average blood loss was 387 cc (range 50 to 1,100) and no patient was transfused. Bladder catheter was removed after an average of 13 days because of the slower tissue healing after irradiation. No death or intraoperative complication occurred. There was no conversion to open surgery. Average postoperative stay was 6.4 days. Average followup was 11.2 months. Of the 7 patients 5 are continent (no pad day or night) and 2 have stress incontinence. All patients are impotent. No patient had urethral stenosis or lymphocele. Prostate specific antigen is lower than 0.1 ng/ml in 5 patients and higher in 2. CONCLUSIONS: Laparoscopic salvage radical prostatectomy after irradiation is feasible with no more morbidity than an open procedure. A longer followup is mandatory to evaluate its usefulness.

Aged↗
PubMed2003

Laser prostatectomy in patients on anticoagulant therapy or with bleeding disorders.

PURPOSE: Bleeding disorders or the use of anticoagulant medication are contraindications to transurethral prostate resection in men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Laser prostatectomy has proved to be adequate surgical therapy with less blood loss than transurethral prostate resection. MATERIALS AND METHODS: A prospective, controlled study was done in patients at high risk (HR) with LUTS suggestive of BPH. They were treated with contact laser prostatectomy (CLP) or the combination of CLP with visual laser ablation prostatectomy (VLAP). HR was defined as bleeding disorders or anticoagulants use. As a control, men at normal risk with LUTS suggestive of BPH were treated with CLP. Patients completed validated questionnaires and underwent urodynamics at baseline and 6 months postoperatively. RESULTS: A total of 75 patients were included, namely 19 in the HR-CLP group, 11 in the HR-CLP-VLAP group and 45 in the normal risk CLP group. Obstruction relief, and symptomatic and subjective improvement were equal in all 3 groups. Effective capacity (maximum cystometric capacity minus post-void residual volume) also improved significantly in all except the HR-CLP group. Maximum urine flow improved in all groups but not significantly in the HR-CLP group. Intraoperative and postoperative complications were slightly higher in HR cases. However, blood transfusion was never necessary and there was no mortality. CONCLUSIONS: CLP and especially CLP-VLAP perform almost as well in HR cases compared with CLP in those at normal risk. These procedures are safe for men at HR with LUTS suggestive of BPH.

Aged↗
PubMed2004

Which conditions contributing to the Charlson score predict survival after radical prostatectomy?

PURPOSE: The Charlson score is likely to be the most frequently used comorbidity measure in prostate cancer. However, to our knowledge the individual prognostic significance of contributing conditions has not been previously studied in a radical prostatectomy sample. MATERIALS AND METHODS: A total of 444 consecutive patients were entered into this study. The 19 conditions contributing to the Charlson score were obtained from the preoperative cardiopulmonary risk assessment and the hospital discharge document. Mantel-Haenszel hazard ratios were estimated for comorbid (noncancer) and overall survival. Thereafter, the Charlson score was refined by excluding conditions with low predictive value. RESULTS: Mean followup was 5.9 years. Only 3 single conditions (congestive heart failure, peripheral vascular disease and severe renal disease) were significantly associated with excess overall mortality. Concerning comorbid mortality, in addition to these 3 diseases, chronic pulmonary disease was associated with increased risk. Refinement of the Charlson score improved the circumscription of patients at risk for premature death after radical prostatectomy. CONCLUSIONS: This study suggests that restricting the Charlson score to some clinically meaningful diseases may increase its usefulness in candidates for radical prostatectomy. The conventional Charlson score did not add clinically meaningful information supplementary to congestive heart failure, which is the most important single contributing condition.

Aged↗
PubMed2004

Lymph node positive prostate cancer: long-term survival data after radical prostatectomy.

PURPOSE: We retrospectively reviewed the outcome in our patients with prostate cancer and regional positive lymph nodes who underwent prostatectomy. MATERIALS AND METHODS: Between January 1984 and December 2002, 147 men were found to have local lymph node metastases after surgery, of whom 135 underwent further androgen ablation, including 88% within 6 weeks after prostatectomy. We especially determined overall, cancer specific and progression-free survival rates. RESULTS: Median patient age was 63.2 years (range 46 to 75 years). Postoperative followup was up to 214 months (median 41.9). There was 1 death secondary to surgery. To date 49 patients (33.3%) had disease progression, including 6 with a prostate specific antigen increase later than 100 months after surgery, and 36 (24.5%) died, including 22 of prostate cancer and 14 of other causes. Overall and cause specific survival probabilities at 5, 10 and 15 years were 76.6% and 86.5%, 60.1% and 73.7%, and 47.2% and 57.9%, respectively. Median overall survival was 144 months and median cancer specific survival was greater than 145 months. Overall progression-free probabilities at 5, 10 and 15 years were 72.7%, 49.8% and 31.6%, respectively. Biochemical progression-free survival rates were 77.4% after 5, 53.0% after 10 and 33.7% after 15 years. CONCLUSIONS: Since three-quarters of our patients were likely not to die of prostate cancer within the 10 years after surgery despite histological evidence of lymph node metastases, radical prostatectomy with or without hormonal therapy is a viable option for patients with local lymph node involvement, particularly in view of long-term survival.

Aged↗
PubMed2004

A systematic review of holmium laser prostatectomy for benign prostatic hyperplasia.

PURPOSE: We undertook a systematic review to assess the safety and efficacy of holmium laser prostatectomy compared to transurethral resection of the prostate. MATERIALS AND METHODS: We searched literature databases through August 2002. Holmium laser studies, including holmium laser resection of the prostate (HoLRP) and holmium laser enucleation of the prostate (HoLEP), of any design, and the transurethral prostatectomy (TURP) arms of randomized controlled trials (RCTs) with sample sizes greater than 50 patients, date restricted to 1995 onward, were included for comparison. RESULTS: Three RCTs comparing HoLRP and TURP, and 2 RCTs comparing HoLEP and TURP were identified. For each of the holmium procedures there was also 1 nonrandomized comparative study and a number of case series (HoLRP 13, HoLEP 10). With the exception of 1 randomized trial the quality of the available evidence was poor, with the other RCTs lacking information regarding methods of randomization, allocation concealment and blinding. The majority of studies were characterized by relatively short followup periods and significant losses to followup. In terms of safety the data suggest that the holmium laser procedures are superior to TURP with regard to a number of key indicators of blood loss (transfusion rates, postoperative bladder irrigation, duration of catheterization and length of hospital stay), although amount of blood loss was rarely reported. In terms of efficacy the holmium laser procedures appear to be similarly effective to TURP in relieving the symptoms of benign prostatic hyperplasia. CONCLUSIONS: Holmium laser prostatectomy is at least as effective as TURP for managing the symptoms of benign prostatic hyperplasia. However, at the present time the long-term durability of the holmium procedures with respect to TURP cannot be determined due to a lack of published studies with sufficient followup.

Holmium↗
PubMed2004

Bulbourethral composite suspension:: a new operative technique for post-prostatectomy incontinence.

PURPOSE: A new bulbourethral sling procedure is proposed for patients with post-radical prostatectomy incontinence. MATERIAL AND METHODS: Bulbourethral composite suspension was performed in 16 consecutive patients, of whom 6 (38%) had severe stress incontinence and depended on a condom urinal catheter. Urinary stress incontinence was assessed preoperatively by a modified pad test, urethrocystoscopy and urodynamic evaluation. The procedure was performed with a longitudinal perineal and a transverse suprapubic incision with the patient under regional anesthesia. We placed a porcine dermis for urethral protection and a polypropylene retropubic sling, which was tied suprapubically with the patient coughing and during retrograde urethral closure pressure monitoring at 60 cm H2O. RESULTS: Preoperative evaluation excluded detrusor instability and urethral stricture. The polypropylene band was placed without neurogenic or vascular complications. All patients had primary wound healing. Patients reported only minimal postoperative pain. Clinical followup was performed a median of 14 months postoperatively (range 6 to 32). Of the 16 patients 11 (69%) were completely dry and 1 (6%) reported improved continence, while 4 (25%) had no benefit, including 2 who underwent an artificial sphincter procedure. Preoperative mean daily pad use decreased from 7 (range 2 to 12) to 1 (range 0 to 10) postoperatively (p = 0.0004) and postoperative quality of life improved significantly (p <0.0001). CONCLUSIONS: Bulbourethral composite suspension is a new, efficient operative sling technique in patients with severe post-prostatectomy stress urinary continence. Because morbidity and complications are low, this new technique may become an alternative to artificial urinary sphincter implantation. Long-term observation of urethral and detrusor function is necessary to elucidate the specific contribution of bulbourethral composite suspension in restoring urinary continence after radical prostatectomy.

Aged↗
PubMed2004

Making ends meet: a cost comparison of laparoscopic and open radical retropubic prostatectomy.

PURPOSE: We compared the perioperative costs of laparoscopic radical prostatectomy (LRP) and open radical retropubic prostatectomy (RRP) at a metropolitan hospital by developing a detailed computer model. MATERIALS AND METHODS: Our predictive model incorporates institutional cost centers for operative time, operating room consumables, professional fees, hospital room and board, oral analgesics, autologous blood banking, blood transfusion and cystography. Versions with and without pelvic lymphadenectomy (PLND) were evaluated using 1 and 2-way sensitivity analyses. Operative times, lengths of stay and transfusion rates were derived from published series. We also reviewed individual hospital charges for 172 consecutive prostatectomy cases for comparison and validation of model predictions. RESULTS: The model predicted cost premiums for LRP of 14.4% (without PLND) and 17.5% (with PLND). The actual hospital charge premium for LRP and PLND was 18.4%, which differed from the predicted cost premium by less than 1%. The most significant cost centers in order of importance were operative time, length of stay and consumables. To achieve cost equivalence with RRP, operative times would need to average 159 minutes (LRP and PLND) and 174 minutes (LRP alone) holding other factors constant. Cost equivalence could not be achieved by shortening hospital stay alone unless LRP were performed as an outpatient procedure. CONCLUSIONS: Our model predicts the perioperative costs of LRP to be greater than RRP by a factor of less than 1.2x. If disposable instruments and trocars are eliminated, and patients undergoing LRP and PLND are discharged on postoperative day 2, cost equivalence with RRP and PLND can be achieved with operative times of 3.4 hours.

Computer Simulation↗
PubMed2004

Androgen replacement after curative radical prostatectomy for prostate cancer in hypogonadal men.

PURPOSE: We documented the experience of 2 urology practices with the use of testosterone supplementation to treat hypogonadal men who had undergone curative radical prostatectomy for localized prostate cancer. We also reviewed the literature for reports of the use of testosterone in men surgically cured of prostate cancer. MATERIALS AND METHODS: A retrospective review of clinical records of 2 busy private urology practices was used to compile brief case histories of hypogonadal men treated with testosterone who had undergone curative radical prostatectomy for localized prostate cancer. Using MEDLINE and BIOSIS Previews (Biological Abstracts, Inc., Philadelphia, Pennsylvania), the literature was searched for articles describing the use of testosterone in men surgically cured of organ confined prostate cancer. RESULTS: The case records of 7 hypogonadal men who had undergone curative radical prostatectomy were identified. All men had clinical symptoms of hypogonadism and low serum testosterone levels. Each man was treated with an androgen preparation. After variable followup periods no biochemical or clinical evidence of cancer recurrence was found in any of the group. No reports in the literature were found of a similar therapeutic approach for such patients. CONCLUSIONS: Based on the clinical experience with this small group of men, and indirect evidence of the safety of this approach from epidemiological and clinical data, further cautious use of testosterone in a carefully selected population seems warranted.

Aged↗
PubMed2004

Impact of margin size on the incidence of local residual tumor after laparoscopic radical prostatectomy.

PURPOSE: Since October 2001 we have performed intraoperative frozen section (IFS) on the posterolateral areas of the radical prostatectomy specimen with bilateral nerve sparing. In cases of positive surgical margin (SMs) the corresponding neurovascular bundle (NVB) was resected. We evaluated the impact of several biological and pathological parameters on the incidence of local residual tumor in the NVB. MATERIALS AND METHODS: A total of 487 laparoscopic radical prostatectomies with bilateral nerve sparing and IFS were performed between October 2001 and December 2003. When IFS was positive, the whole NVB was removed and analyzed after fixation in serial sections. The size of the positive SM was measured in its largest dimension. The association of NVB residual tumor with positive SM size, preoperative prostate specific antigen, pathological stage and Gleason score was analyzed using the t and chi-square tests, and logistic regression. RESULTS: Of the 487 patients 84 had a positive SM on IFS. In 25 of the 84 additionally resected NVBs we found residual tumor. On univariate and multivariate analysis the only predictor of residual tumor was positive SM size (p<0.001). In all cases of a positive SM of 0.1 cm or less we found no residual tumor cells in the NVB. CONCLUSIONS: In case of a positive SM in the posterolateral area of the prostatectomy specimen margin size is predictive of the incidence of residual tumor in the corresponding NVB. This finding could help management and the decision about local adjuvant treatment.

Adult↗