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PubMed2000

Outcome prediction with p53 immunostaining after radical prostatectomy in patients with locally advanced prostate cancer.

PURPOSE: Conventional pathological variables in prostate cancer may not provide optimal prediction of patient outcome. Pathological findings and p53 immunostaining were measured prospectively in radical prostatectomy specimens to determine the incremental improvement in prediction of patient outcome over clinical findings. MATERIALS AND METHODS: From a previous prospective study of 392 consecutive patients with prostate cancer who did not receive preoperative therapy and were treated with radical prostatectomy 25 had pathological stage pT3aN0M0, 24 had pT3bN0M0, 2 had pT2bN1M0, 7 had pT3aN1M0 and 14 had pT3bN1 prostate cancer. These locally advanced stage cases comprise the current study population and further analysis was done with p53 immunostaining. All prostate specimens were totally embedded, serially sectioned and whole mounted. We examined pathological, clinical and laboratory findings as well as p53 immunostaining. RESULTS: Median followup was 5.4 years (range 0.5 to 6.4). Univariate analysis revealed that pathological stage, 10% or greater immunostaining for p53, area and length of extraprostatic cancer extension, and cancer volume (all p </=0.03) were associated with biochemical (prostate specific antigen) or clinical failure. When all variables were considered in stepwise multivariate analysis none attained statistical significance after p53 status entered the model (p <0.01, risk ratio 2.9 for 10% or greater versus less than 10%, 95% confidence interval 1.4-6.2). The concordance index analysis for the predictive ability of prostate specific antigen, stage, grade and ploidy (c = 0.66) was inferior to the predictive ability of a statistical model also including p53 status (c = 0.71). CONCLUSIONS: In cases of locally advanced stage cancer p53 immunoreactivity after radical prostatectomy improves outcome prediction. Addition of this variable to those routinely determined may identify a subset of patients who would benefit from more intensive postoperative surveillance and adjuvant therapy.

Aged↗
PubMed2000

The pathophysiology of post-radical prostatectomy incontinence: a clinical and video urodynamic study.

PURPOSE: We examine various mechanisms of post-radical prostatectomy incontinence. MATERIALS AND METHODS: A total of 83 consecutive men (mean age 68 +/- 6.6 years) referred for evaluation of persistent post-radical prostatectomy incontinence were enrolled in the study. All patients underwent clinical and urodynamic evaluation. Final diagnosis was based on clinical judgment considering patient history, pad test, voiding diary, free (unintubated) uroflow measurements, video urodynamics and linear passive urethral resistance relation curves. We compared free uroflow and pressure flow obtained with a 7Fr urethral catheter in place, and empirically defined low urethral compliance as at least 10 ml. per second difference between these measurements. RESULTS: Sphincteric incontinence was the most common urodynamic finding, occurring in 73 patients (88%). Detrusor instability was identified in 28 patients (33.7%) and in 6 (7.2%) was the main cause of incontinence. In 2 other patients bladder outlet obstruction (1.2%) or impaired detrusor contractility (1.2%) was the only urodynamic finding. Impaired detrusor contractility was diagnosed by linear passive urethral resistance relation in 82% of cases but considered to be clinically relevant in only a third. In 25 cases (30.1%) low urethral compliance was noted, which we consider nearly synonymous with urethral scarring. CONCLUSIONS: Sphincteric incontinence is the most common urodynamic finding in patients with post-radical prostatectomy incontinence, although other findings may coexist. The most accurate diagnosis is attained when all objective measures are put in perspective with the clinical setting.

Aged↗
PubMed2000

Radical prostatectomy for localized prostate cancer provides durable cancer control with excellent quality of life: a structured debate.

PURPOSE: To cure localized prostate cancer, the entire prostate must be eliminated, which is what all forms of treatment must achieve. Although there is no better way to cure localized disease than total surgical removal, the challenge is whether this can be accomplished with acceptable morbidity. MATERIALS AND METHODS: To evaluate quality of life following radical retropubic prostatectomy, patient reported outcomes of 62 men who underwent radical retropubic prostatectomy at this institution were recorded during the first 18 months of followup. By 18 months 93% of the patients were dry (wearing no pads) and 93% to 98% characterized urinary bothersomeness as none or small. Potency, defined as the ability to achieve unassisted intercourse with or without the use of sildenafil, improved gradually and by 18 months 86% of the patients were potent and 84% considered sexual bothersomeness as none or small. In an effort to improve the outcome of radical prostatectomy, the surgical procedures on these 62 patients were videotaped prospectively. The videotapes were reviewed 18 months after the study was initiated and 4 specific steps in the surgical procedure were correlated with patient reported outcomes. Surgeons who wish to improve their outcomes should consider using this technique to identify in their own hands other important arbitrary variations that may improve results. RESULTS: The probability of maintaining an undetectable prostate specific antigen was evaluated in men with similar pathological stages of disease who were or were not potent following surgery. Men who were potent had the same outcome as those who were impotent, supporting the premise that preservation of sexual function does not compromise cancer control. Cancer control and quality of life following brachytherapy were analyzed and the following conclusions were made: 1) high dose intensification is necessary if radiation therapy is expected to cure prostate cancer but I doubt that any form of radiotherapy will produce durable cancer control for 20 to 30 years; 2) although brachytherapy is rarely adequate as monotherapy, I am not certain that brachytherapy combined with external beam radiotherapy is any better than 3-dimensional conformal therapy alone and the side effects are uncertain, and 3) I believe that a prostate specific antigen nadir of less than 0.2 ng./ml. is necessary to confirm an adequate response to radiation. CONCLUSIONS: I believe that there is no better way to cure organ confined cancer than total surgical removal. Today continence and potency rates should be high. If not, a review of intraoperative videotapes of successful and unsuccessful cases can improve results. In men treated with radiotherapy stringent criteria for treatment response and quality of life outcomes are needed.

Adenocarcinoma↗
PubMed2000

High frequency of clonal chromosome abnormalities in prostatic neoplasms sampled by prostatectomy or ultrasound-guided needle biopsy.

Cancer of the prostate remains poorly characterized cytogenetically. This is due in part to methodological problems and in part to the paucity of radical prostatectomies, until now the main source of material for cytogenetic analyses. We have improved existing techniques for the culturing of prostatic neoplasms removed by radical prostatectomy or sampled by ultrasound-guided needle biopsy. Successful short-term cultures were obtained from all 10 prostatectomy samples and from all 10 ultrasound-guided needle biopsies, always with a pure epithelial morphology. Of the 19 cases yielding a sufficient number of high-quality metaphases for chromosome banding analysis, the single atypical epithelial hyperplasia had a normal karyotype, whereas both prostatic intraepithelial neoplasias and 12 of 16 (75%) invasive carcinomas were shown to have clonal abnormalities. Ten of the 12 (83%) karyotypically abnormal invasive carcinomas presented structural chromosomal rearrangements. A recurrent deletion, del(10)(p13), was seen in three tumors; in one of them the terminal nature of the deletion was confirmed by two-color FISH. A del(17)(p11) was seen in one PIN lesion, but since the analysis of exons 4-8 of the TP53 tumor suppressor gene revealed no mutations, there probably was no inactivation of the second TP53 allele. Our study thus leads to the following main conclusions. First, better culturing methods allow the detection of abnormal karyotypes in a much higher percentage of prostatic neoplasms than has hitherto been possible. Second, ultrasound-guided needle biopsies of prostatic neoplasms are a sufficient source of material for cytogenetic analysis. Third, a terminal deletion of the short arm of chromosome 10, del(10)(p13), seems to identify a subgroup of prostatic cancer.

Biopsy, Needle↗
PubMed2000

Management of a positive surgical margin after radical prostatectomy: decision analysis.

PURPOSE: We created and tested a decision analysis model to help determine the preferred management of a positive surgical margin(s) after radical prostatectomy. MATERIALS AND METHODS: We constructed a decision tree modeling surveillance versus immediate prophylactic adjuvant radiation in patients with a positive surgical margin(s) after radical prostatectomy. Literature and institution based estimates were determined for certain factors, including the probability of undetectable prostate specific antigen (PSA) in patients followed expectantly postoperatively and those treated with immediate adjuvant radiotherapy, complications of radiotherapy after prostatectomy and probability of undetectable PSA in those treated with therapeutic radiation for detectable PSA postoperatively. A panel of experts assigned utilities to the various outcomes. Sensitivity analysis was performed to determine threshold values required to change the model outcome. RESULTS: Using average probability estimates from a literature review the decision model recommended initial surveillance. Sensitivity analysis demonstrated that the model depended on the probability of disease recurrence in men followed expectantly after surgery as well as the efficacy of therapeutic radiation. We tested the decision model again for patient groups based on tumor grade, pathological stage, preoperative PSA and number of positive margins. The model recommended initial radiation for patients with low to intermediate grade disease, no evidence of seminal vesicle invasion and multiple positive margins. CONCLUSIONS: The results of our decision analysis imply that immediate radiation may be appropriate for patients with a positive surgical margin(s) and a high likelihood of recurrent local rather than distant disease. This model may be useful to physicians and patients who use individual probability estimates and utility values to determine the preferred course of management after surgery.

Decision Trees↗
PubMed2000

A randomized phase 3 study of intraoperative cavernous nerve stimulation with penile tumescence monitoring to improve nerve sparing during radical prostatectomy.

PURPOSE: We determine if mapping of the cavernous nerve during radical prostatectomy using intraoperative cavernous nerve stimulation with tumescence monitoring results in improved erectile potency compared to conventional nerve sparing. MATERIALS AND METHODS: A prospective, randomized, single blinded study was performed on 61 patients at 6 centers. Patients had elected to undergo nerve sparing prostatectomy and had normal preoperative erectile function documented by the Sexual Function Inventory Questionnaire (SFIQ) and RigiScan parallel testing. Patients were randomized between conventional nerve sparing and nerve sparing assisted by the CaverMap Surgical Aid. paragraph sign In all patients neural continuity was assessed immediately after prostate removal by proximal cavernous nerve stimulation. All patients were blinded according to their allocation cohort. RESULTS: At 1 year there was substantial improvement in erectile function in the CaverMap group as measured by RigiScan. This group had a mean of 15. 9 minutes of greater than 60% nocturnal tumescence compared to 2.1 minutes in the conventional nerve sparing group (p <0.024). By SFIQ there was a nonsignificant trend to improved potency in the CaverMap group (71% versus 62%, p = 0.17). Of patients who had bilateral, unilateral and no response to stimulation after resection erectile function assessed by SFIQ recovered in 68%, 27% and 0%, respectively (p = 0.016). CONCLUSIONS: CaverMap assisted prostatectomy led to improved erectile function as assessed by RigiScan testing with no associated adverse events. A response to stimulation immediately after removal of the prostate accurately predicted return of erectile function.

Adult↗
PubMed2000

[Methods and results of radical prostatectomy for localized cancer of the prostate].

A radical prostatectomy for localized prostate cancer is indicated after evaluation of the disease (initial PSA, clinical stage, biopsy mapping, results of radiologic explorations with an endorectal MRI) and the patient (age, morbidity, life expectancy and wishes of potency conservation). The surgical approaches, retropubic or laparoscopic, depend on the surgeon's experience. Radical prostatectomy provides good disease-free survival for organ-confined disease close to the natural life expectancy. Post-radical prostatectomy morbidity is essentially represented by orthostatic incontinence (up to 6.8%), stress incontinence (up to 27%) and impotence (30 to 95%), depending on the published series and patient age.

Humans↗
PubMed2000

Changes in fibrinolytic activity of blood after prostatectomy.

After prostatectomy, hypofibrinogenemia and bleeding were reported earlier. The objective of present study is to find out, of blood, after prostatectomy. Blood samples of patients posted for operations were studied by following tests before and after operation along with controls. 1. Euglobulin lysis time. 2. Plasminogen assay. 3. Fibrinogen estimation. The results showed clearly that there is decrease in euglobulin lysis time indicating increased plasminogen activator level, increased plasminogen level and decreased fibrinogen level after the operation. This suggests that there is significant increase in fibrinolytic activity of blood after prostatectomy leading to hypofibrinogenemia and clotting defects.

Aged↗
PubMedDate not supplied

Analysis of molecular isoforms of PSA and their ratios in men with PSA-relapse after radical prostatectomy.

BACKGROUND: The aim of this study was the longitudinal comparison of % f-PSA in patients before radical prostatectomy and after PSA relapse. Is % f-PSA a consistent tumor specific parameter or does this ratio change during untreated tumor progression? MATERIALS AND METHODS: In this study 41 out of 420 patients with untreated increasing PSA-progression (> 0.5 ng/ml) were analysed. Patients with neoadjuvant or adjuvant hormonal therapy were excluded. T-PSA were f-PSA were analyzed by Immulite DPC (Diagnostic Products Coop., CA) and Abbott Axsym (Abbott Park, Il, USA). RESULTS: Pre-operative % f-PSA ratio was 10.6% (range 4.6-22%; Std. dev.: 4.9); T-PSA concentration was 26.4 ng/ml (range 5.5-10.2 ng/ml Std. dev.: 20.3). In men with PSA relapse after radical prostatectomy % f-PSA ratio was 14.73% (range 2.2-4.5% Std. dev.: 9.7). Repeated post-operative % f-PSA measurements resulted in 12.94% f-PSA (range 2.7-3.8% Std. dev.: 9.9%) with a regression of R = 0.57. All men with pre-operative elevated % f-PSA (> 15%) had post-operative elevated % f-PSA. CONCLUSIONS: The data indicates that post-operative % f-PSA is a constant tumor specific parameter in men with untreated PSA relapse after radical prostatectomy. Post-operative % f-PSA was higher compared with pre-operative % f-PSA concentrations. No correlation with Gleason score or pathological stage was found.

Humans↗
PubMed2001

[Secondary biological recurrence after radical prostatectomy: multivariate analysis of prognostic clinical, biological, and histologic factors].

OBJECTIVES: To define the clinical, laboratory and histological variables associated with secondary elevation, after an undetectable phase, of PSA after radical prostatectomy. MATERIALS AND METHODS: This was a prospective study of 83 consecutive patients undergoing retropubic radical prostatectomy with an undetectable postoperative PSA at 3 months. The predictive value of five preoperative criteria (age, total PSA, Gleason score on biopsies, positive apical biopsies, clinical stage) and four postoperative criteria (pathological stage, Gleason score on the operative specimen, positive margins, follow-up) for secondary laboratory progression was studied by univariate and multivariate analysis. RESULTS: With a median follow-up of 36 months, the laboratory recurrence rate was 19%. Laboratory recurrence was associated with a biopsy Gleason score greater than or equal to 7 (p = 0.04), a high pathological stage (p = 0.03), a high histological score (Gleason > or = 7) (p < 0.01) and positive margins (p = 0.04). Logistic regression identified a Gleason score on the operative specimen greater than or equal to 7 to be the only element predictive of secondary laboratory progression. CONCLUSION: The concept of positive margins or high pathological stage is insufficient to identify the risk of laboratory progression after radical prostatectomy. The Gleason score, which evaluates tumour aggressiveness, the risk of micrometastases or periprostatic extension, therefore appears to be more useful.

Adenocarcinoma↗
PubMed2001

[Correlation between imaging findings and anatomopathologic results in radical prostatectomy. Data from our series].

OBJECTIVE: To analyze the diagnostic methods utilized in prostate cancer and the preoperative information on the extent of the tumor, and compare these results with those obtained from anatomopathological analyses of the radical prostatectomy specimen. METHODS: Data on the radical prostatectomies performed during the study period were obtained from the Admissions and Clinical Records services and were analyzed using the SPSS statistical analysis software for Windows. RESULTS: From 1991 to 1998, 109 radical prostatectomies were performed. Evaluation by transrectal US was carried out in 89 patients (81.6%) and detected a tumor (unilateral or bilateral) in 77, for a sensitivity of 86% (CI 78.8-93.2). A CT study was performed in 94 patients and was positive in 25, for a sensitivity of 26.5% (CI 17.6-35.4). The sensitivity for transrectal US and CT were 4.17% and 3.33% for capsular involvement, 5.88% and 5.26% for seminal vesicle involvement, and 0% and 0% for node involvement, respectively. CONCLUSIONS: Transrectal ultrasound is a reliable diagnostic imaging method, although it has a low sensitivity when used to determine the extent of the tumor. In our series, the radiological methods showed a low sensitivity when they were utilized to determine the extent of the prostate cancer. Routine preoperative assessment by CT can be obviated in prostate cancer.

Aged↗
PubMed2001

Randomized comparative study of 3 versus 8-month neoadjuvant hormonal therapy before radical prostatectomy: biochemical and pathological effects.

PURPOSE: A prospective phase 3 trial was initiated to determine whether 8 compared with 3-month neoadjuvant hormonal therapy reduces prostate specific antigen (PSA) recurrence rates after radical prostatectomy. Our interim analysis includes secondary end points of differences in biochemistry, pathology and adverse events between the 2 groups. MATERIALS AND METHODS: Men with clinically confined prostate cancer were randomized to receive 7.5 mg. leuprolide intramuscularly monthly and 250 mg. flutamide orally 3 times daily for 3 or 8 months before radical prostatectomy. Our study was powered to detect a 35% decrease in PSA recurrence, assuming a 30% recurrence rate in the 3-month arm after 3 years. RESULTS: A total of 547 men were randomized between August 1995 and April 1998. Men in the 8 and 3-month groups were equally stratified for T stage (29% T1c, 70% T2), Gleason grade (68% less than 4, 32% 4 or greater) and pretreatment PSA (63% less than 10, 27% 10 to 20 and 10% greater than 20 microg./l.). Mean pretreatment PSA was slightly higher in the 8-month compared with the 3-month group (11.64 versus 9.95 microg./l., respectively, p = 0.0539). A total of 44 men withdrew from study before surgery and, therefore, were nonevaluable. Preoperative PSA nadir was less than 0.1 microg./l. in 43.3% versus 75.1% (p <0.0001), and 0.3 microg./l. or greater in 21% versus 9.2% after 3 versus 8 months, respectively (p <0.0006). Mean serum PSA decreased 98% to 0.12 microg./l. after 3 months, with a further 57% to 0.052 microg./l. from 3 to 8 months. Transrectal ultrasound determined that prostatic volume decreased 37% from a mean of 40.6 to 25.4 cc after 3-month neoadjuvant hormonal therapy (p = 0.0001) and a further 13% to 22.2 cc after 8 months (p = 0.03). Mean hemoglobin decreased 15% (148.2 to 125.4 gm./dl.) after 3-month neoadjuvant hormonal therapy but stabilized thereafter. Radical prostatectomy was completed in 500 men, while surgery was aborted intraoperatively in 3. Positive margin rates were significantly lower in the 8 than 3-month group (12% versus 23%, respectively, p = 0.0106). There were no fatal adverse events and no differences between the 2 groups in the severity or causality (p = 0.287, 0.0564) of adverse events, or incidence of increased liver enzymes or diarrhea (p = 0.691, 0.288, respectively). However, men in the 8-month group noticed a higher number of newly reported adverse events (4.5 versus 2.9, p <0.0001) and higher incidence of hot flushes than the 3-month group (87% versus 72%, respectively, p <0.0001). CONCLUSIONS: Ongoing biochemical and pathological regression of prostate tumors occurs between 3 and 8 months of neoadjuvant hormonal therapy, suggesting that the optimal duration of neoadjuvant hormonal therapy is longer than 3 months. Longer followup is needed to determine whether longer therapy alters PSA recurrence rates.

Androgen Antagonists↗
PubMed2001

Long-term continence and patient satisfaction after artificial sphincter implantation for urinary incontinence after prostatectomy.

PURPOSE: We assess long-term continence and patient satisfaction after implantation of the AMS Sphincter 800 (American Medical Systems, Minnetonka, Minnesota) in men who were incontinent after total and subtotal prostatectomy. MATERIALS AND METHODS: Patients who had an artificial urinary sphincter implanted for urinary incontinence after prostatectomy and a minimum of 20 months of followup were identified from a patient database. The medical records of these 209 patients were reviewed, and a questionnaire was mailed. Telephone contact was attempted with patients who did not respond to the questionnaire. Of the 209 patients 11 (5%) had undergone device removal, 34 (16%) were deceased and an additional 51 (24%) could not be contacted for followup. Our study group consisted of the 113 patients with artificial urinary sphincters who could be contacted for followup. Mean followup was 73 months (range 20 to 170). RESULTS: There were 4 (4%) patients who were dry and continent and 68 (60%) were incontinent using 0 to 1 pad daily. An additional 35 (31%) patients required 2 to 3 pads daily and 5 (4%) used more than 3 daily. There were 14 (12%) patients who had undergone surgical revision of the device. Of the 113 patients 31 (28%) were very satisfied, 50 (45%) satisfied, 20 (18%) neutral, 7 (6%) dissatisfied and 4 (4%) very dissatisfied. One patient was not using his device to control continence. CONCLUSIONS: Artificial urinary sphincter implantation offers men who are incontinent after prostatectomy a reasonable chance for obtaining long-term satisfactory urinary control, although complete continence is unusual.

Follow-Up Studies↗
PubMed2001

Life after radical prostatectomy: a longitudinal study.

PURPOSE: We investigate the longitudinal recovery of quality of life after radical prostatectomy in men with localized prostate cancer. MATERIALS AND METHODS: We assessed the self-reported health related quality of life in 247 men undergoing radical prostatectomy for prostate cancer. Patients were assessed at baseline before surgery and postoperatively every 3 months for 1 year and then every 6 months for up to 48 months (median 30). We measured general and prostate specific health related quality of life with the RAND 36-Item Health Survey 1.0 SF-36 and University of California, Los Angeles Prostate Cancer Index. The Cox proportional hazards regression model was used to determine whether some patients were more likely than others to have a successful return to baseline functioning after treatment. RESULTS: In the SF-36 60% of patients reached baseline in all domains by 3 months. By 12 months, greater than 90% of patients reached baseline in all domains. Mean recovery time for these domains was about 4(1/2) months. The recovery of urinary function to baseline was 21% at 3, 56% at 12 and 63% at 30 months, respectively. About 80% of patients recovered to baseline urinary bother. In the urinary domains patients who recovered did so at an average of 7 to 8 months, and there was little additional recovery after 18 months. By 1 year postoperatively, approximately a third of patients reached baseline sexual function and about half recovered to baseline sexual bother. At 2 years postoperatively, sexual function and bother returned to baseline in 40% and 60% of patients, respectively. Mean recovery time was about 11 months for sexual function and about 9 months for sexual bother. There was little additional recovery in the sexual domains after 18 to 24 months. In the bowel domains more than two thirds of patients returned to baseline by 3 months, and greater than 90% recovered by 12 months, with a mean recovery of 4.8 months. Unmarried men were more likely than those married to regain baseline sexual function (p = 0.03) and urinary function (p = 0.07). Patients who were 65 years and older were more likely than those younger to return to baseline sexual bother (p = 0.03). There were trends that showed patients with higher incomes as well as those who were white were more likely to recover baseline scores for urinary function and the physical component summary. Another trend suggested that men with a higher education were less likely to regain urinary function (p = 0.08). CONCLUSIONS: Most quality of life recovery occurs early after radical prostatectomy, except in several domains, including urinary and sexual, which continue to improve even beyond 2 years postoperatively. Patients should be encouraged that recovery may continue for months or years after surgery.

Aged↗
PubMed2001

Assessment of early continence recovery after radical prostatectomy: patient reported symptoms and impairment.

PURPOSE: Patients considering radical prostatectomy often inquire as to when they can expect to regain urinary continence. However, there is a paucity of patient self-reported data regarding the recovery of continence during the initial 3 months after surgery. Our objectives were to assess urinary continence changes early in the postoperative period and determine which of 2 commonly used definitions of continence more closely relate to patient reported urinary impairment. MATERIALS AND METHODS: A prospective study of 90 men with clinically localized prostate cancer who selected radical prostatectomy as primary therapy was conducted. Repeated measures of urinary continence as defined by 1) total urinary control, 2) the use of 1 or 0 pads daily, and 3) small or no problem with urinary function were obtained with a brief survey preoperatively and postoperatively. RESULTS: At 56 days after removal of urethral catheters, the actuarial rates of urinary continence recovery based on definitions 1 to 3 were 43%, 84% and 82%, respectively. The use of definition 2 for continence resulted in a 1.9 times higher actuarial rate for continence recovery when compared to definition 1 at 56 days (p <0.001). However, strong agreement was observed between definitions 2 and 3 (kappa = 0.69). CONCLUSIONS: Urinary control is recovered in a significant proportion of men who undergo radical prostatectomy during the initial 3 months. Continence rates will vary significantly based on the use of alternative definitions. The clinical practice of asking patients how many pads daily they use may be valid, as it corresponds well to the impairment they have.

Aged↗
PubMed2001

Revision rate after artificial urinary sphincter implantation for incontinence after radical prostatectomy: actuarial analysis.

PURPOSE: We determined the actuarial revision rate for artificial urinary sphincters implanted in patients who were incontinent after radical prostatectomy. MATERIALS AND METHODS: We reviewed the records of 70 consecutive patients who were incontinent after radical prostatectomy and who underwent primary artificial urinary sphincter implantation at the University of Michigan between 1984 and 1999. Questionnaires were mailed to all patients with an indwelling device, and telephone calls were placed to those who did not respond to the mailing. Information about surgical revision and current continence status was obtained from chart review and questionnaire response. The Kaplan-Meier curves for actuarial freedom from operative revision were constructed. RESULTS: Of the 66 patients with available postoperative data 24 (36%) required reoperation at a mean followup of 41 months. The 5-year actuarial rate for freedom from any operative revision was 50%, and the corresponding rate for cuff revision was 60%. A single operative revision did not predispose the patient to further revision. Questionnaire data indicated a continence rate of 80% (range 0 to 2 pads). CONCLUSIONS: Approximately half of the patients who were incontinent after radical prostatectomy may expect to undergo operative revision within 5 years after artificial urinary sphincter implantation. Despite this high reoperation rate, an excellent level of continence is maintained.

Actuarial Analysis↗
PubMed2001

Early removal of the catheter after laparoscopic radical prostatectomy.

PURPOSE: We prospectively tested the safety of routine removal of the catheter as early as 2 to 4 days after laparoscopic radical prostatectomy. MATERIALS AND METHODS: Between March 1998 and March 2001, 228 patients underwent laparoscopic radical prostatectomy for clinically organ confined prostate cancer. The last 113 consecutive patients were included in a prospective study according to gravitational cystography performed 2 to 4 days postoperatively. If no leak was seen the catheter was removed. If a leak was apparent the catheter was left indwelling for another 6 days and cystography was repeated. RESULTS: Cystography 2 to 4 days postoperatively showed an anastomosis without a leak in 96 (84.9%) patients who subsequently had the catheters removed. There were 28 patients who had the catheter removed on postoperative day 2, 28 day 3 and 40 day 4. In 17 (15.1%) patients an anastomotic leak was observed, and the catheter was not removed at that time. Of the 96 patients in whom the catheter was removed early 10 (10.4%) had urinary retention that necessitated re-catheterization. This procedure was performed without the need for cystoscopy. After the catheter was removed all patients were able to void 24 hours later. Median followup was 7 months (range 1 to 15) and showed continence rates greater than 93%. No anastomotic stricture, pelvic abscess or urinoma developed in any patient. CONCLUSIONS: Patients who undergo laparoscopic radical prostatectomy can have the catheter safely removed 2 to 4 days postoperatively without a higher risk of incontinence, stricture or leak related problems.

Humans↗
PubMed2001

Artificial urinary sphincter for post-radical prostatectomy urinary incontinence: long-term subjective results.

PURPOSE: Incontinence affects between 3% and 60% of patients after radical prostatectomy. Insertion of an artificial urinary sphincter is a mainstay therapeutic option available to these patients. We assessed patient satisfaction, outcome and complications long after artificial urinary sphincter implantation. MATERIALS AND METHODS: From a data bank of 131 patients who underwent artificial urinary sphincter prosthesis insertion we identified 71 with a mean age of 72 years who had also undergone radical prostatectomy and were available for evaluation. This group included 29 patients (40.8%) who received an earlier version of the AMS-800 (American Medical Systems, Minnetonka, Minnesota) and 42 (59.2%) who received the newer narrow back cuff device. Information on surgical procedures and followup were obtained from a computerized database. Patients were also contacted by an impartial reviewer who administered a standard telephone questionnaire on the degree of continence, complications, other means used to help with urinary continence, proficiency in device operation and satisfaction. RESULTS: At a mean followup of 7.7 years (range 0.5 to 16) 19 patients (27%) used 0, 23 (32%) used 1, 11 (15%) used 1 to 3 and 18 (25%) used more than 3 daily, while 1 used an external catheter. Surgical revision in 21 cases (29%) was required due to mechanical failure in 18 (25%), device erosion in 3 (4%) and infection in 1 (1.4%). The need for revision correlated significantly with the design of the sphincter (p = 0.005). Only 7 of the 42 patients in whom a narrow cuff AMS-800 was implanted needed revision versus 18 of the 23 with a previous design. Mean time to revision was 2.5 years (range 0.5 to 8). The device was removed in 2 cases (2.8%). Of the patients 41 (58%) are very satisfied, 14 (19%) are satisfied and 16 (23%) are unsatisfied with the device. The degree of satisfaction correlated with the number of pads used (p = 0.0005) and sphincter design (0.028) but not with the number of surgical revisions (p = 0.521) or patient age. CONCLUSIONS: The artificial urinary sphincter is a viable treatment option for post-radical prostatectomy incontinence with a high rate of continence and satisfaction for a long period after the procedure. Patients should be informed that complications necessitating device revision and explantation may appear late in followup. A standard definition of treatment success and studies of homogenous groups of patients with an artificial urinary sphincter would enable better understanding and patient education in the future.

Aged↗