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PubMed1993

Transurethral prostatectomy versus transurethral dilatation of the prostatic urethra for benign prostatic hyperplasia: a cost-utility analysis.

Transurethral prostatectomy is the treatment currently preferred for benign prostatic hyperplasia. A new procedure, transurethral dilatation of the prostatic urethra, has lower costs and mortality and complication rates but may be less effective. These two strategies were evaluated by using cost-utility analysis, a form of cost-effectiveness analysis in which the benefit is defined in terms of individual preferences. Under the model assumptions, the cost of transurethral dilatation is less than the cost of transurethral prostatectomy for patients with benign prostatic hyperplasia ($7084 versus $8647) and slightly more effective: 11.787 quality adjusted life years versus 11.766. Thus, transurethral prostatectomy is said to be dominated. Results indicate that if patients are rigorously selected, and if balloon catheters of 30-35mm in size are utilized, transurethral dilatation could be the initial treatment of choice for eligible patients with benign prostatic hyperplasia.

Catheterization↗
PubMed1976

[The treatment of locally confined prostatic carcinoma: radiotherapy versus total prostatectomy (author's transl)].

Recent data show that carcinoma of the prostate is not radioresistant. But not all prostatic cancers are radiosensitive. All information available in the literature on histologically proven local destruction of prostatic cancer tissue, all survival data and reported complications after radiation treatment are reviewed and discussed. The results of radical surgical treatment from various authors but mainly from the series of Belt and Schröder are used for comparison. From these data it is evident that total prostatectomy of stage B and C tumors is superior to radiation therapy as far as local eradication of tumor goes. Five- and ten-year actuarial survival rates are about identical for stage B disease but favor total prostatectomy in stage C patients. Sexual impotence, the most important lasting complication of total prostatectomy, is present in 23-47% of patients after radiotherapy. Urinary incontinence is not known after irradiation but reported after surgery. Long term damage of the lower urinary tract, the gastrointestinal system, or the lymphatics was reported in 2-24% of patients after radiotherapy. The indication for radiation treatment in stage D patients is very questionable. Exact surgical staging by iliac and obturator lymphadenectomy is desirable to rule out stage D disease in locally confined tumors. Radiation treatment is indicated in patients who are not willing to undergo surgery, who are unwilling to accept sexual impotence, or who are poor candidates for surgery from other reasons.

Cell Transformation, Neoplastic↗
PubMed1994

[Radical prostatectomy after complete androgen blockade in stage B2 and C cancer].

Despite recent advances in imaging techniques, the staging process is still unsatisfactory in cancer of the prostate. The underestimation for stage B2 and C tumours in about 50%. We present our findings in a retrospective study analyzing the clinical and biological effects of complete androgen blockade before radical prostatectomy in patients with advanced stage localized tumours. We treated 21 patients from 1989 to 1993. All received preoperative homonotherapy by complete androgen block for at least 3 months before node dissection preceding suprapubic radical prostatectomy. Only 20 prostatectomies were performed as metastasis was found in the extemporaneous examination in 1 patient. The volume of the prostate gland had diminished in all patients after the hormonotherapy (27.8%) as did PSA (95%). When evaluated, the tumour stage of the surgical specimen was always more advanced than the needle biopsy. Only 1 tumour was strictly limited to the intracapsule and all the others had either invaded the capsule, reached the margins or had invaded the seminal vessels or lymph nodes. With a mean follow up of 45 months, recurrence rate is 50%, mainly due to tumours with positive margins or seminal invasion in patients who were not given adjuvant treatment. Our results are in agreement with those in the literature showing that although the volume of the prostate is reduced and PSA declines, no improvement in pathology staging is observed.

Aged↗
PubMed1995

Impact of physician awareness on hospital charges for radical retropubic prostatectomy.

PURPOSE: We determine if physician awareness of hospital costs for radical retropubic prostatectomy affects physician practice patterns. MATERIALS AND METHODS: We reviewed 256 consecutive radical retropubic prostatectomies performed by 14 urologists during 4 years at a community hospital. After 2 years the physicians were provided information on factors that may decrease charges. RESULTS: Charges decreased significantly following intervention, from +f417,134 within the initial 2 years to +f413,826 within the last 2 years (p < 0.005). Significant decreases were noted for length of stay, need for intensive care, operating time and blood loss. CONCLUSIONS: Traditional methods of physician education can impact practice patterns to decrease hospital charges for radical retropubic prostatectomy.

Adult↗
PubMed1994

Morbidity of pelvic lymphadenectomy, radical retropubic prostatectomy and external radiotherapy in patients with localised prostatic cancer.

Staging pelvic lymphadenectomy (PLND) was performed in 210 prostatic cancer patients (mean age 67 years, clinical stage T0-T3 M0). A radical retropubic prostatectomy was subsequently performed in 54 men, ten of whom also received postoperative radiotherapy due to positive surgical margins. Ninety-eight patients were treated with external beam radiation alone (70 Gy in 35 fractions) and the remaining 58 received endocrine therapy. The complications of PLND alone (156 patients), consisted of wound infection in eight patients, hematoma or lymphocele in seven, venous thrombosis in three, and cardiac infarction in one patient. Early side-effects of radiotherapy included mild to moderate proctitis and/or cystitis in 57 patients. One year after completion of therapy, 48 of the irradiated men had proctitis, but only six had severe symptoms. Four patients developed radiation cystitis and two urethral stricture. Following prostatectomy (54 patients), two patients died in pulmonary embolism and another one developed a deep venous thrombosis. Hematoma occurred in five patients. Of the 42 surviving patients who did not receive postoperative radiotherapy, eight developed anastomotic strictures and four had severe stress incontinence. Only five were fully potent one year after surgery. Eight of the ten patients receiving radiotherapy after prostatectomy developed side-effects from the intestine and/or the urinary bladder. Two of them became totally incontinent. One developed a severe hemorrhagic cystitis necessitating urinary diversion. All ten were impotent after treatment.

Aged↗
PubMed1995

Experience with radical prostatectomy and radiation therapy for localized prostate cancer at a Veterans Affairs Medical Center.

We assessed the actuarial survival of 357 patients with localized prostate cancer who were treated with radical prostatectomy or radiation therapy at a Veterans Affairs Medical Center between 1980 and 1991 and who were followed for a median of 59 months. During this period patients with clinical stages A2 and B tumors who had an anticipated life expectancy of 10 years or greater were generally treated with surgery. Patients with stages A2 and B tumors who were not candidates for surgery and those with stage C tumors were generally treated with radiation therapy. There were no significant differences among the cause specific, clinical disease-free and prostate specific antigen disease-free survival curves of patients with stages A2 and B tumors who were treated with radical prostatectomy (138) or radiation therapy (138) but the all cause and metastases-free survival curves favored the surgery group (p < 0.000001 and 0.046, respectively). There was no significant difference between the all cause survival curves of the patients with stages A2 and B tumors and of 81 patients with stage C tumors who were treated with radiation therapy. However, the cause specific survival curves favored the patients with stages A2 and B tumors (p = 0.000007). This study demonstrates that there is a high risk of death from co-morbidities in a hospital based population of American veterans with localized prostate cancer who are not candidates for radical prostatectomy.

Actuarial Analysis↗
PubMed1994

[Indications for radical prostatectomy in localized cancer of the prostate].

The exceptional character of the natural history of prostate cancer continues to feed the controversy about the indication of radical prostatectomy in localised prostatic cancer. However, the correlation between tumor volume and the risk of disease progression established by recent pathological studies seems to demonstrate an ideal indication for radical prostatectomy for a tumor volume between 0.5 and 4 cc. However the precise estimation of this tumor volume by current diagnostic tools is still insufficient. Nevertheless, recent publications show that radical prostatectomy, whose complications must not be overestimated, gives real chances of obtaining good local control of the disease, even for advanced localised cancers. This operation can be rationally proposed to people with a sufficiently long life expectancy.

Humans↗
PubMed1994

A postal survey evaluation of prostatectomy.

BACKGROUND: The aims of this study were to determine the prevalence of urinary symptoms after prostatectomy, and the relationship between pre- and post-operative symptoms. METHODS: A retrospective postal survey was carried out, on an unselected series of patients in Leicestershire, one to two years after transurethral resection. Four hundred and sixty-five men received a questionnaire, and of these 78 per cent responded. RESULTS: The operation relieved 92 per cent of all preoperative urge-incontinence, but 3 per cent of those who were continent beforehand developed urge-incontinence. Urgency and hesitancy also responded well. Nocturia, frequency and dribbling were the least responsive. There was a general tendency for symptoms to persist rather than develop post-operatively. CONCLUSIONS: Prostatectomy is an effective intervention, particularly for cases with urge-incontinence, urgency, incontinence or hesitancy. These results are consistent with those of other, prospective, studies. Postal surveys may provide a cheap and effective method of evaluating local prostatectomy services.

Aged↗
PubMed1993

The role of transrectal ultrasound-guided staging biopsy and androgen ablation therapy prior to radical prostatectomy.

Radical prostatectomy is the most common therapy for localized prostate cancer. Unfortunately, resection is associated with positive surgical margins in 35-50% of cases. We report the use of ultrasound-guided staging biopsies to stage tumors preoperatively with greater accuracy. We also report the use of androgen ablation therapy (AAT) as an adjunct to radical prostatectomy in an attempt to downstage tumors preoperatively and decrease the incidence of positive margins. Between 1 June 1991 and 31 July 1992, 131 patients underwent radical prostatectomies, 119 of whom underwent AAT before surgery and 12 of whom did not. Specimens were examined for the presence of positive surgical margins, extracapsular extension, and perineural invasion. Cases pretreated with AAT had a 9.2% positive surgical margin rate compared with 33% in untreated subjects. Extracapsular extension was seen in 22 of 119 (18.5%) of AAT, and 5 of 12 (41.7%) of non-AAT, cases. Perineural invasion was nearly 3 times less likely in AAT patients. Moreover, perineural invasion was significantly less marked in AAT patients. We present a subset of 11 patients who were definitively proven as pathologic stage C cancer by transrectal ultrasound (TRUS)-guided needle biopsy. These cases had prostate cancer intermixed with fatty tissue and pigmented seminal vesicle epithelium, elements not found in the prostate. In this selected stage C subset, gland shrinkage, evidence of downstaging, and tumor obliteration were seen after AAT. We conclude that TRUS-guided staging biopsy can definitively stage prostate cancer as stage C when tumor is intermixed with extraprostatic elements, and AAT appears to decrease the incidence of positive surgical margins by tumoral necrosis and selective perineural kill. We believe that these findings demonstrate the antitumor effects of AAT and deserve further scrutiny in a large randomized clinical trial.

Androgen Antagonists↗
PubMed1993

Hormone ablation therapy as neoadjuvant treatment to radical prostatectomy.

Two hundred consecutive patients with presumed localized prostate cancer had radical prostatectomy alone (n = 119) or were treated for an average period of 3 months with combination therapy using the antiandrogen flutamide and one luteinizing hormone-releasing hormone (LHRH) agonist (Lupron or Zoladex). The positive margins decreased from 35.3% in the group undergoing prostatectomy alone to 11.5% in the group of men who received combination therapy before radical prostatectomy. In 41 apical tumors, the incidence of positive margins decreased from 50% in the control group to 18.6% in the combination therapy group. In stage C disease, the incidence of positive tumor showed a tendency to decrease with the extended duration of endocrine treatment with a rate of 37.5% after 3 months and 16.7% after 6 months. Whether the decreased incidence of positive surgical margins will all translate into prolonged survival remains to be verified by long-term follow-up of these patients. However, the initial results obtained in the present study are very encouraging.

Aged↗
PubMed1994

Gleason histologic grading in prostatic carcinoma. Correlation of 18-gauge core biopsy with prostatectomy.

Histologic grading of adenocarcinoma of the prostate gland is a reliable predictor of extension and metastasis. Studies involving correlation of grade between biopsy and prostatectomy specimens have traditionally involved biopsies using a large-bore (14-gauge) cutting needle. However, common practice has shifted to the use of biopsy cores with a smaller caliber (18 gauge). This study was undertaken to determine the degree of correlation of tumor grade between 18-gauge core biopsy samples and excised glands. Sixty-seven patients with stage A or B adenocarcinoma of the prostate gland who had previously undergone 18-gauge core biopsy, who underwent radical prostatectomies, were studied. The Gleason score was determined by referred consensus among three pathologists. There was exact agreement between biopsy and excision in 39 cases (58%), whereas 24 cases (36%) differed by one digit. Three cases (4.5%) were undergraded, and one case (1.5%) was overgraded by two or more points. Only six tumors (8.9%) would have been incorrectly specified by the degree of differentiation. Discrepancies in grade of two points or more were not more frequent in cases with a small tumor volume (< or = 10%) in the biopsy specimens. We concluded that with careful histologic evaluation, the grade of tumor identified in these smaller biopsy cores correlates well with that seen at prostatectomy.

Adenocarcinoma↗
PubMed1993

Effect of continuous irrigation with normal saline after prostatectomy.

Normal saline solution is often used for continuous irrigation of the bladder following prostatectomy in order to prevent clot retention. There is usually a concern for possible sodium reabsorption and consequent fluid retention. Considering the harmful cardiovascular effect in elderly patients who usually come for prostatectomy, fluid retention could be detrimental. Therefore we have hitherto given daily lasix injections routinely during continuous irrigation of the bladder with normal saline solution. This study is designed to find out if the amount of sodium reabsorbed is significant enough to justify the practice. The amount reabsorbed is indeed not significant (p > 0.05). A plea is therefore made to give lasix injection following prostatectomy only if there is a clinical indication for it.

Adult↗
PubMed1993

["Single potential analysis of cavernous electric activity" (SPACE). Findings before and after surgical dissection of the cavernous nerves within the scope of radical prostatectomy].

Single potential analysis of cavernous electric activity (SPACE) is said to give information on the integrity of the central and peripheral parts of the autonomic nervous system insofar as it is involved in erectile function. A total of 30 patients who underwent radical prostatectomy with simultaneous severance of the cavernous nerves as treatment for locally advanced cancer were investigated by SPACE before and after the operation. The findings were compared to the those recorded on two different dates in 20 age-matched men who had not undergone surgery and in whom there was no evidence of any lesion of the autonomic nervous system. Even in this control group, few reproducible results were found. Nevertheless, with reference to the items "number of wedges" (i.e. monophasic elements with amplitudes of 25-100 microV) and "maximum amplitudes" of SPACE potentials there was a more than change correlation of the values on the two test dates, which was not found in the prostatectomy group. Although this difference between the two groups investigated was statistically significant, these findings cannot be interpreted as an effect of autonomic denervation of the cavernous bodies. This is attributed to the fact that the postoperative results in the prostatectomy group were more similar to the findings in the control group than to the preoperative measurements taken while the autonomic innervation was still intact. Therefore, our investigations lead us to conclude that routine application of SPACE as a direct check on the integrity of the autonomic nerve fibres involved in erectile dysfunction is not justified at present.

Adult↗
PubMed1993

Methods of radical prostatectomy specimen processing: a novel technique for harvesting fresh prostate cancer tissue and review of processing techniques.

Standard processing techniques for radical prostatectomy specimens uniformly require initial formalin fixation. Fresh prostate cancer tissue is needed for many types of prostate cancer research and may be needed for diagnostic purposes in the future. We describe a method for processing radical prostatectomy specimens that allows pre-fixation sectioning and harvest of fresh prostate cancer tissue. Because of increased difficulty interpreting capsular margin sections, however, we do not recommend it for routine use. We review other methods of radical prostatectomy specimen processing and provide an algorithm for their appropriate use.

Algorithms↗
PubMed1996

Radical perineal prostatectomy without pelvic lymphadenectomy: selection criteria and early results.

PURPOSE: We evaluated the surgical efficacy of radical perineal prostatectomy and determined preoperative parameters to identify patients at low risk for nodal metastasis. MATERIALS AND METHODS: Of 155 men evaluated for radical perineal prostatectomy, 74 were assigned to a low risk category (prostate specific antigen less than 10 ng./ml., Gleason score less than 7). Of the patients 40 underwent laparoscopic lymph node dissection and 34 did not. This group was compared to 81 patients who underwent surgical staging and did not fit the low risk criteria. RESULTS: None of 74 patients in the low risk group had nodal metastasis, while metastasis was present in 5 of 81 (6.1%) who did not meet such parameters. Organ-confined disease was present in 71.6% of men with low risk criteria, which was a significantly different rate than the 51.9% found in the other 81 men. CONCLUSIONS: Radical perineal prostatectomy confers adequate cancer control and can be performed without pelvic node dissection in select patients.

Aged↗
PubMed1995

A randomised single institution study comparing laser prostatectomy and transurethral resection of the prostate.

We concluded a prospective randomised study comparing conventional electrocautery transurethral resection of the prostate (TURP) to laser prostatectomy using a right-angled Nd:YAG beam reflector. Seventy-one patients were evaluable, 34 laser and 37 TURP. Fifty patients have completed 6 months of follow-up. Using standard post prostatectomy outcome parameters of maximum flow rate and post void residual urine, laser prostatectomy shows equivalence at 6 months, with mean maximum flow rates of 8.76 ml/sec preoperatively improving to 15.47 ml/sec at 6 months, whilst for TURP patients, flow rates improved from a mean of 9.48 ml/sec preoperatively to 19.1 ml/sec at 6 months. Symptom scores remain higher for the laser patients at this time with a mean score of 9.27 compared to 4.43 for TURP patients. However, morbidity in the laser group is less, particularly given the absence of postoperative bleeding and the necessity for blood transfusion.

Aged↗
PubMed1996

Applied stapling technique in radical retropubic prostatectomy: efficient, effective and efficacious.

PURPOSE: We demonstrated the efficiency, efficacy and effectiveness of the endoscopic gastrointestinal anastomosis (GIA) stapler in radical retropubic prostatectomy. MATERIALS AND METHODS: A total of 21 patients with organ confined prostate cancer on preoperative staging underwent radical retropubic prostatectomy. During these procedures we analyzed the applicability and efficacy of the endoscopic GIA vascular stapler to effect ligation, division and stapling of the dorsal vein complex and lateral pedicles of the prostate. This group was compared to 7 controls in whom we performed surgery for organ confined disease, using the stapler solely for the lateral prostatic pedicles or not at all depending on availability. One patient with localized muscle invasive transitional cell carcinoma of the bladder underwent radical cystectomy using the endoscopic GIA stapler in a sequential fashion to ligate and divide all pedicles of the specimen. RESULTS: Mean total operative time was 2 hours (range 1 hour 40 minutes to 2 hours 50 minutes) and average estimated blood loss was 400 cc. All patients were discharged from the hospital on postoperative day 3. To date 17 of the 21 patients are continent and 6 are potent. CONCLUSIONS: Although not designed to replace the standard approach to radical retropubic prostatectomy, we believe that this technique makes the procedure easier and more approachable in the hands of the less experienced surgeon.

Humans↗
PubMed1996

Transurethral collagen injections in the therapy of post-radical prostatectomy stress incontinence.

PURPOSE: We report on our initial results with glutaraldehyde cross-linked collagen used as an injectable bulking agent for the therapy of post-radical prostatectomy stress incontinence. MATERIALS AND METHODS: A total of 19 men underwent collagen injection for treatment of post-radical prostatectomy stress incontinence. RESULTS: Of the 19 patients treated 11 had either a good (4) or improved (7) result, for an overall satisfaction rate of 58% with a followup of 3 to 15 months (mean 10.4). Failure correlated with presence of bladder neck contracture or scarring and severity of incontinence. CONCLUSIONS: Injection of collagen for stress incontinence after radical prostatectomy has an acceptable short-term success rate, particularly in men with milder incontinence and lack of bladder neck scarring.

Collagen↗