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PubMed1996

Factors affecting change in quality of life after prostatectomy for benign prostatic hypertrophy: the impact of surgical techniques.

PURPOSE: The impact of prostatectomy on quality of life was assessed in patients with benign prostatic hypertrophy (BPH) who were classified according to the expected benefit from surgical intervention. The relative impact of the 2 surgical techniques (open versus closed) on short-term quality of life was compared. MATERIALS AND METHODS: An observational study was done on 545 consecutive patients with BPH undergoing prostatectomy at 3 medical centers in Israel between 1991 and 1992. Repeated structured interviews preoperatively, and at 4 and 12 months postoperatively were performed, including 6 quality of life questionnaires evaluating BPH specific (symptom severity and symptom effect) and generic (activity, independence, mental health and health perception) parameters. In addition, the interviews consisted of socio-demographic data elements. Clinical details regarding severity of prostatic disease and co-morbidity were obtained from the medical charts. RESULTS: We found a correlation between postoperative change in symptom effect and in generic quality of life measures (r-0.11 to 0.20, p < 0.04). The postoperative decrease in the mean symptom effect score was 56% and 52% for severe and moderate preoperative levels, respectively. There was no decrease in the mean symptom effect score for the mild preoperative level (18% of these patients had postoperative deterioration). A secondary operation, and the combination of diabetes mellitus and poor activity level were risk factors for lack of improvement in patients with moderate preoperative symptom effects. We found that the impact of open prostatectomy on quality of life was similar to that of the closed technique after adjustment for patient attributes, except for those with an indwelling urinary catheter in whom an open operation was advantageous. CONCLUSIONS: In patients with BPH and mild symptom effects, and in subgroups of patients with moderate symptom effects surgery should not be recommended. Based on short-term measures of quality of life there is no justification for a preference between open and closed operations.

Aged↗
PubMed1995

The incidence of prostate cancer progression with undetectable serum prostate specific antigen in a series of 394 radical prostatectomies.

PURPOSE: Serum prostate specific antigen (PSA) has been reported to be a sensitive indicator of recurrent carcinoma after radical prostatectomy but it is not absolute. Disease progression with undetectable PSA levels has been described but the incidence of this phenomenon is unknown. MATERIALS AND METHODS: We retrospectively analyzed the records of 394 consecutive men who underwent radical prostatectomy between 1980 and 1991 to characterize the incidence of recurrent carcinoma despite undetectable serum PSA levels. RESULTS: Of the 394 men 133 had documented evidence of disease recurrence, 3 (2.3%) despite undetectable serum PSA levels (2 had local and systemic evidence of disease progression). Histological dedifferentiation characterized these recurrences. CONCLUSIONS: Although a post-prostatectomy detectable serum PSA level precedes clinical evidence of disease progression by years, rare patients (2.3% in our series) in whom recurrent disease is characterized by marked histological dedifferentiation will remain negative for PSA.

Aged↗
PubMed1993

Serum PSA after anatomic radical prostatectomy. The Johns Hopkins experience after 10 years.

1. With an average follow-up of 53 months (range 12-120 months), 19.4% (185/955) of men have had a cancer recurrence after radical prostatectomy for clinically localized prostate cancer. A detectable serum PSA was the only evidence of recurrence in 11.2%, whereas 2.2% have had a recurrence locally and 6% with distant metastases. 2. The actuarial status at 10 years was 70% for undetectable serum PSA; 23% for isolated serum PSA elevation only; 7% for distant metastases; and 4% for local recurrence. 3. In our study, no patient demonstrated disease progression (local or distant) without detectable serum PSA. 4. The actuarial likelihood of an elevated serum PSA increased with increasing clinical stage, Gleason score, preoperative serum PSA concentration, and pathologic stage. 5. The actuarial recurrence rate for tumors with a Gleason score of 7 was not statistically different from the recurrence rate for lesions of Gleason score 8-10. 6. There exist marked differences in actuarial recurrence-free probabilities for men with tumors of low Gleason score (< 7) compared with those with tumors of high Gleason score (> or = 7) when there is pathologically established capsular penetration. 7. Patients with preoperative serum PSA concentrations greater than 10.0 ng/mL are at a statistically increased risk of recurrence. 8. Men who have detectable serum PSA within the first year after surgery are at a significantly higher risk of disease progression than those men who have measurable serum PSA in postoperative years two and three. 9. Men with an isolated elevation of serum PSA after radical prostatectomy have a 25% likelihood of harboring an occult local recurrence. However, radiation therapy produces a sustained suppression of PSA to undetectable levels for 2 years or more in only 10% of men. This suggests that radiation therapy is not effective in sterilizing occult local residual tumor in many men. 10. Valuable information concerning disease recurrence and progression can be obtained through early postoperative measurement of serum PSA. This article demonstrates the long-term value of serum PSA as a measure of progression after anatomic radical prostatectomy.

Follow-Up Studies↗
PubMed1994

Prostate specific antigen progression rates after radical prostatectomy or radiation therapy for localized prostate cancer.

BACKGROUND: The purpose of the study was to determine whether a difference is noted in the rate of prostate specific antigen (PSA) elevation after radical prostatectomy or radiation therapy for localized prostate cancer. METHODS: PSA doubling times were calculated by linear regression analysis in 50 patients who had been treated by radical prostatectomy and who had three or more increasing PSA levels and in 55 patients who had been treated with radiation therapy and who had three or more increasing PSA levels. RESULTS: No significant difference was noted in the mean PSA doubling times in the two patient groups when stratified by the site of tumor recurrence or by pretreatment tumor stage, tumor grade, or acid phosphatase level. CONCLUSIONS: Because the PSA doubling time probably parallels the tumor growth rate, these data suggest that the malignant potentials of recurrent tumor after radical prostatectomy and after radiation therapy are equivalent.

Humans↗
PubMed1994

Follow-up after radical prostatectomy or radiation therapy for prostate cancer.

The use of the serum marker prostate-specific antigen (PSA) has altered drastically the follow-up after prostate cancer. PSA is far superior to any other method of detecting recurrences after either radiation therapy or radical prostatectomy. Once the PSA reaches a nadir level after radiation therapy or becomes undetectable after radical prostatectomy, it should remain at that level. PSA provides a lead time of approximately 3 to 7 years prior to identification of recurrence or metastases by other traditional methods. The yield of diagnostic studies to identify the site of recurrence in patients with very low levels of PSA after radical prostatectomy is quite low. A substantial dilemma remains about optimal therapy once a rising PSA is identified.

Follow-Up Studies↗
PubMed1995

Variable histology of anastomotic biopsies with detectable prostate specific antigen after radical prostatectomy.

Progressive elevation of the prostate specific antigen (PSA) level after radical prostatectomy for adenocarcinoma is generally considered as irrefutable evidence of recurrent tumor. We assessed the results of 62 biopsies of the vesicourethral anastomosis in 41 men who had 3 or more consecutive PSA levels of 0.4 ng./ml. or greater after radical prostatectomy and no evidence of metastatic disease. The median PSA at the time of the first biopsy was 2.2 ng./ml. (range 0.4 to 50). Histological confirmation of recurrent cancer was established after 1 biopsy procedure in 39% of the patients and after 1 or more biopsy procedures in 59%. Biopsy was positive in 78% of 23 patients with an abnormal digital rectal examination, 40% of 5 with an abnormal transrectal ultrasound only, and 23% of 13 with a normal digital rectal examination and ultrasound. Among the patients with and without biopsy proved tumor recurrence there were no significant differences between the pathological stage or histological grade of the primary tumors, the month after surgery of the first detectable PSA level, the PSA doubling time, the month after surgery of the positive biopsy or the last negative biopsy, and the PSA level at the time of the positive biopsy or the last negative biopsy. In 6 cases benign prostatic tissue only was recovered from 1 or more biopsy specimens. This experience demonstrates that in patients with a detectable PSA after radical prostatectomy recurrent cancer may be difficult to document by biopsy of the vesicourethral anastomosis.

Anastomosis, Surgical↗
PubMed1995

Acute urinary retention in men: a comparison of voiding and nonvoiding patients after prostatectomy.

Multiple parameters were examined preoperatively to determine if any could predict successful voiding after prostatectomy in male patients who present in acute urinary retention due to benign prostatic hypertrophy. A total of 50 men 50 to 85 years old (mean age 69.5 years) who presented with this clinical picture was investigated with multichannel urodynamic studies, and completed the American Urological Association (AUA) symptom score for benign prostatic hypertrophy preoperatively and postoperatively. All patients underwent prostatectomy. Mean retention volume was 1,172 cc (range 500 to 2,100). Mean preoperative and postoperative AUA symptom scores were 15.5 and 5.0, respectively. At 3 months postoperatively 45 patients (90%) were able to void without catheterization. At 16.6 months 5 patients still required clean intermittent catheterization to empty the bladder. Postoperatively, there was a statistically significant improvement in AUA symptom score, opening voiding pressure and peak flow rate. The AUA symptom score was not predictive of either impending acute retention or normal voiding after prostatectomy. In our patients no preoperative parameters were statistically different between those voiding and those on clean intermittent catheterization. However, poor sensation, large retention volumes, lack of instability and no voluntary detrusor contractions were more common in the nonvoiding men.

Acute Disease↗
PubMed1995

[Perioperative and postoperative complications of pelvic lymphadenectomy and radical prostatectomy in 320 consecutive patients].

To examine the intra- and postoperative morbidity of radical retropubic prostatectomy we analyzed the first 320 consecutive patients with clinical stages T1b, T2a-c and negative lymph nodes by frozen section. Patient age varied from 42 to 75 years (mean 63.5 years). In 74.7% the estimated blood loss was less than 1500 ml. With a preoperative autologous blood collection program the intraoperative blood requirement for homologous blood units was only 15%. Intraoperative complications included rectal injuries with vesical rectal fistulas in 2.5% and ureteral injuries in 1.6%. Within the perioperative period the mortality rate was 0.9%. At 12 months after surgery 199 of 218 men (90.9%) were continent, 5.1% had minimal urinary incontinence, and only 4.6% had urinary incontinence grade III. Postoperatively, PSA (prostate-specific antigen) decreased to < 0.5% in 90.4% of the patients after radical prostatectomy. At 12 months after operation PSA was < 0.5 ng/ml in 83.4%. We conclude that radical retropubic prostatectomy is a safe procedure for the curative treatment of localized prostate cancer.

Aged↗
PubMed1995

[Results of 15 years of radical prostatectomy].

From July 1969 to May 1994, radical prostatectomy was performed in 630 patients with clinically localized prostate cancer at the Department of Urology, University of Würzburg Medical School. These included 74 patients subsequently followed up for 15 years or more 15 years (15-23 years, mean 17.5 years), who were the subjects of the present study. Of these 74 patients 59 had pT2 tumors and 10 had pT3 tumors according to the staging criteria of the 1992 edition of the UICC TNM classification. The remaining 5 patients had microscopic lymph node metastases detected at staging pelvic lymphadenectomy (stage pT2-3pN1-2). Patients with lymph node involvement were treated by immediate orchiectomy. All other patients received no further treatment until progression occurred. The overall 15-year survival rate actually observed the 74 patients was 50% (37/74) and the disease-free survival rate was 43.2% (32/74 pts). Stage-related overall and disease-free survival rates were found to be 54.2% and 49.1%, respectively, for patients with pT2 tumors, 40% and 30% for those with pT3 tumors, and 20% and 0 for patients with lymph node metastases. Progression (either local recurrence or distant metastatic spread) was noted in 22 of the 74 patients (29.7%) within the 15-year period following radical prostatectomy. Mean time to progression was 7.9 years (3 months to 17 years). Within the follow-up period, 17 patients (23%) died of prostate cancer. These actual 15-year follow-up data show radical prostatectomy to be the most effective means of achieving long-term disease-free survival, if not cure, in patients with clinically localized prostate cancer.

Adult↗
PubMed1995

Radical prostatectomy, radiotherapy or deferred treatment for localized prostate cancer?

Before considering the possible biases discussed above, the results as reported in the current literature may indicate an advantage for radical prostatectomy in disease specific survival at 10 years' follow-up when compared with external radiation therapy and deferred treatment. It appears that most of the obvious biases found in the literature work in favour of radical prostatectomy. The actual advantage of radical prostatectomy with respect to disease specific survival at 10 years may therefore be less than the data complications suggest. The magnitude of these biases is, however, impossible to assess. A probable but perhaps marginal benefit for the majority of the patients must, however, be put in relation to possible side effects and long term complications of the various treatments as well as the patient's preferences when choosing treatment. Reliable controlled data on outcome and quality of life for the various treatments of localized prostate cancer are needed, but we may have to wait for many years for such data. It must also be remembered that the results presented in this overview derive from a series started in the late 1970s of patients treated with the surgical techniques and radiotherapy technology available at that time. Today, the frequent use of prostate specific antigen in early detection or screening programmes will definitely detect a larger number of low volume prostate cancers that may be more curable by surgery or radiotherapy. This, however, remains to be proved. Moreover, new technology in radiotherapy, such as conformal therapy, may enable radiotherapists to deliver higher local doses of radiation to the prostate, which in turn may improve the cure rate for radiotherapy.

Humans↗
PubMed1995

Downstaging by combination therapy with flutamide and an LHRH agonist before radical prostatectomy.

A total of 161 patients diagnosed as having stage B (134 patients) or C (27 patients) prostate cancer were randomly assigned to radical prostatectomy alone or to 3 months of neoadjuvant combination therapy with the anti-androgen flutamide and an LHRH agonist before radical prostatectomy. Neoadjuvant combination therapy before radical prostatectomy decreased cancer positive surgical margins from 33.8% in the control group to only 7.8%, thus leaving 92.2% of patients with negative margins at surgery for a 39.2% increase in specimen confined disease. Although on average the final stage determined at histopathological examination of the surgical specimen was more advanced than predicted at initial diagnosis in 33.8% of control patients, an opposite observation was made in the group of men who received the 3 month neoadjuvant combination therapy where the final stage, instead of being more advanced, was less advanced than at diagnosis in an average of 21.1% of men for a net 54.9% improvement of staging in favour of combination therapy. On the other hand, organ confined disease increased from 49.3% to 77.8% of patients after 3 months of combination therapy, for a 57.9% increase in the incidence of organ confined disease. Although long term follow up of these patients is required to determine the impact on survival, the marked influence of neoadjuvant combination therapy on the stage of the disease suggests the possibility of a major improvement in the morbidity and mortality from prostate cancer.

Aged↗
PubMed1995

[Is there a place for radical prostatectomy without lymphadenectomy?].

OBJECTIVES: Herein we present the procedure we have followed to determine N+ low-risk factors which allow us to identify those patients with prostate cancer in whom radical perineal prostatectomy (RPP) can be performed without a previous staging lymphadenectomy, thereby maintaining the oncological principles but with less morbidity. METHODS: In a series of 88 patients who underwent RPP, we identified an N+ low-risk factor group; i.e., patients with clinically localized tumor of the prostate gland, a Gleason score of < or = 7 and PSA < or = 10 ng/ml. The foregoing criteria were based on the findings reported by Stamey and the status of the lymph nodes of our own series of radical prostatectomies. RESULTS: In 71 of the 88 patients with a follow up of more than one year, RPP was performed after laparoscopic pelvic lymphadenectomy. Of these 71 patients, 17 (19.3%) presented the above-mentioned low-risk characteristics and were all pN-. Since then, the subsequent patients who met this low-risk criteria (n = 17; 19.3% of the total) were submitted to RPP alone without previous staging lymphadenectomy. The rate of positive margins in this group was 17.6%, all cases maintaining PSA within feminization levels after a mean follow-up of 21.7 months. Considering the overall series, 38.6% of the patients could have avoided lymphadenectomy according to our criteria. CONCLUSIONS: We have found RPP without previous staging lymphadenectomy to be a valid therapeutic option for patients with clinically localized prostate cancer, preoperative PSA < or = 10 ng/ml and a Gleason score of < or = 7. According to our data, this group accounts for approximately 40% of the patients in whom radical prostatectomy had been recommended.

Follow-Up Studies↗
PubMed1995

[Radical prostatectomy: comparison of technics].

From 1989 until today 46 patients aged 44-75 years underwent a radical prostatectomy two of whom transperineal and another 44 patients underwent a retropubical prostatectomy (twenty of whom with the nerve sparing technique). Based on our experience, the clinical stages that benefit from a radical prostatectomy as are as followed: T1b, T1c, T2a, T2b; T2c, in patients who present a good A.S.A., a remaining life-span of ten years is expected. Our preference, regarding the best access was clearly the traditional retropubical which allowed us on a preliminary bases a bilateral iliaco-otturatorial lymphoadenectomy with extemporaneus histological exams. Based on our experience we do not see an indication for a radical surgical intervention in the following with: P.S.A. higher than 60 ng./ml in patients with a clinical stage C. Positive abdominal-pelvical computer tomography for macrometastical lymph nodes. Positive bone scintigraphy. Patients over the age of 75 years.

Aged↗
PubMed1995

[Radical perineal and retropubic prostatectomy: comparison of technics].

Today we may consider radical perineal prostatectomy as an example of mild invasive surgery compared with the retropubic. Technique is found less traumatic account of the precision of the approach, the accuracy of hemostasis and urethral bladder suture and the speed of postoperative handling. The only disadvantage related with the impossibility of transperineal pathological lymph node staging can today be satisfactory overcome after the advent of laparoscopic lymph node methods which permits safe non invasive preoperative hystological examination. The authors show the technique of laparoscopic and surgical therapy, concluding that perineal prostatectomy is a better approach toward retropubic radical prostatectomy, if combined with preoperative laparoscopic pelvic lymphadenectomy.

Humans↗
PubMed1995

[Stress urinary incontinence after perineal radical prostatectomy].

22 pts treated by radical perineal prostatectomy have been submitted to pelvic floor training soon after catheter removal, in order to assess faster continence reappraisal than that normally described in literature. 18 pts resulted dry within 4 months from surgical care. 2 pts resulted with stabilized mild stress incontinence due to daytime activity within 6 months from prostatectomy. 2 pts complained strong stress urinary incontinence over a period of more 9 months from surgery, but none resulted affected from continuous leakage. In this pts we observed a maximum time of continence reappraisal of 6 months with a minimum of 1 and an average of 4. An high perineal test has been found statistically correlated in the first three months from surgery with nocturnal continence reappraisal and the begging of diurnal micturion events (p < 0.005). Pelvic floor exercises has been found useful in the treatment of post radical perineal prostatectomy stress urinary incontinence.

Aged↗
PubMed1995

An outcome study of patient-controlled morphine analgesia, with or without ketorolac, following radical retropubic prostatectomy.

PURPOSE: We compared the effects of postoperative pain control strategies on recovery after radical retropubic prostatectomy. MATERIALS AND METHODS: The results in 22 consecutive patients who underwent radical retropubic prostatectomy between 1993 and 1994 were evaluated. Pain control was achieved using morphine patient-controlled analgesia in 11 patients or nonsteroidal anti-inflammatory ketorolac in 11. Outcome measures were compared between the 2 groups. RESULTS: The interval to return of bowel function, length of hospitalization and total hospital costs were significantly decreased in the ketorolac treated patients. CONCLUSIONS: Pain control with ketorolac affords excellent analgesia while allowing for earlier recovery of bowel function, shorter hospitalization and lower overall costs in patients undergoing radical retropubic prostatectomy.

Aged↗
PubMed1995

The incidence and management of rectal injury associated with radical prostatectomy in a community based urology practice.

PURPOSE: We assessed the use of combination bowel preparation before radical prostatectomy. MATERIALS AND METHODS: We reviewed 533 radical prostatectomies performed from 1984 to 1994. All patients underwent preoperative combination bowel preparation. The incidence, management and sequelae of rectal injury were determined. The literature addressing the management of rectal injuries was reviewed. RESULTS: Rectal injury occurred in 8 patients (1.5%). Injury was recognized intraoperatively and repaired primarily in 6 cases, and repair included colostomy in 2. Injury was recognized postoperatively as recto-urinary fistula in 2 cases and initial management was conservative. No fistula closed with conservative management. There were no pelvic abscesses and no deaths. CONCLUSIONS: Combination bowel preparation permits safe closure of rectal injury at radical prostatectomy without the necessity of routine colostomy. In the event of recto-urinary fistula, conservative management is not warranted.

Humans↗
PubMed1995

[A perineal radical prostatectomy technic for localized prostatic cancer].

In the absence of an indication for pelvic lymph node dissection or when this has already been performed by other procedures, perineal radical prostatectomy provides excellent local control of localized prostatic cancer. By respecting the local and general contraindications (volume of the prostate, suppleness of the hip joint, cardiovascular status), perineal prostatectomy ensures good quality resection strictly identical to that obtained by retropubic prostatectomy. The time to return of continence is unchanged. The only problem consists of the difficulty of preserving the neurovascular pedicles responsible for erection. Pre- and postoperative care, as well as surgical technique, are described to provide the reader with an overview of this attractive surgical technique.

Anastomosis, Surgical↗