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PubMed1993

Modified apical dissection for early continence after radical prostatectomy.

A prospective evaluation of urinary continence in 83 consecutive patients undergoing radical prostatectomy using a modified apical urethral dissection is described. Using this technique, complete continence has been achieved in 88%, with stress incontinence in 11% and total incontinence in 1%. Continence was achieved in less than 1 week to a maximum of 16 weeks, with 17% dry during the first week, 53% dry by 6 weeks, and 81% by 3 months. Median time to continence was 5 weeks. Median age of the continent patients was significantly lower than that of incontinent patients. Neither the number of neurovascular bundles resected, the need to reconstruct the vesical neck, nor the number of anastomotic sutures used affected the rate of continence. The described technique, which incorporates the fascia posterior to the urethra into the vesicourethral anastomosis, results in earlier continence after radical prostatectomy, and thereby lessens the morbidity of this procedure.

Adult↗
PubMed1995

Clearance of serum PSA after open surgery for benign prostatic hypertrophy, radical cystectomy, and radical prostatectomy.

OBJECTIVE: To study the clearance of serum prostate-specific antigen (PSA) after several types of prostatic tissue ablation. METHODS: Serum PSA levels were measured (YANG Proscheck ultrasensitive assay) just before surgery, immediately after specimen removal, then twice weekly for 5 weeks or until it was undetectable (< 0.05 ng/ml) in patients undergoing radical cystoprostatectomy for bladder cancer (n = 10), or radical prostatectomy for T1 T2 prostate cancer (n = 18) and daily for 6 days after open surgery for benign prostatic hypertrophy (BPH) (n = 10). RESULTS: Open enucleation for BPH: the immediately postoperative PSA level was 6 times its preoperative value. It decreased following a monoexponential curve with a very short half-life of 0.55 +/- 0.39 days, range (0.14-1.3), reaching a value lower than the preoperative level in all cases, except one by day 3. After radical cystoprostatectomy: the decrease of serum PSA is monoexponential with a half life of 1.92 +/- 1.2 days (0.57-4.24) reaching undetectable level (< 0.05 ng/ml) in all patients by day 21. After radical prostatectomy: 11/18 patients (61%) showed a one-component exponential decrease in PSA with a half-life of 2.5 +/- 1.33 days (range 0.97-4.6 days), and 7/18 showed a two-component exponential decrease with a first half-life of 0.94 +/- 0.8 days and a second of 7.62 +/- 6.35 days); 100% of the patients reached undetectable serum PSA by day 28 in the first group compared to 14.2% of the patients with a two component exponential decrease (P < 0.01). There was no difference between these groups as far as preoperative PSA levels and specimen pathology were concerned. CONCLUSION: Serum clearance of PSA after extirpative prostatic surgery is closely related to the type and indication of procedure used. Radical cystoprostatectomy is probably the best model in which to study the pharmacokinetics of PSA.

Cystectomy↗
PubMed1995

Prognostic significance of capsular invasion and capsular penetration in patients with clinically localized prostate cancer undergoing radical prostatectomy.

One hundred thirty patients with an observed follow-up of more than 10 years after radical prostatectomy were restaged with regard to local extent of the tumor in relation to the prostate capsule. Of 112 patients with surgically staged negative pelvic lymph nodes, 62 had a tumor-free prostate capsule, 24 had capsular invasion without penetration, and 26 had tumors extending through the capsule of the prostate. Observed overall and disease-free 10-year-survival rates were 79% and 69.4%, respectively, in patients with absence of capsular involvement and 70.8% and 66.7%, respectively, in patients with capsular invasion alone. In patients with capsular penetration, however, the survival rates significantly decreased to 57.7% (P = 0.018) and to 38.5 (P = 0.017), respectively. The overall progression rate was found to be significantly higher in patients with tumors extending through the prostatic capsule (46.2%), as compared to those with absence of capsular involvement (21%; P = 0.014) as well as to those with capsular invasion alone without penetration (25%; P = 0.034). Thus, in contrast to capsular invasion alone, capsular penetration means a poor prognostic indicator, which accounts for a reduced survival expectancy and a higher progression rate following radical prostatectomy. Therefore, tumors with capsular invasion and those with capsular penetration should not be grouped together in the same tumor stage as done in the 1987 edition of the TNM tumor classification system.

Adult↗
PubMed1993

Prediction of tumor recurrence after radical prostatectomy using elimination kinetics of prostate-specific antigen.

The serum half-life of prostate-specific antigen (PSA) calculated subsequent to radical prostatectomy can serve to predict which patients are at high risk of bearing residual prostatic carcinoma despite their initial attainment of undetectable PSA serum levels. This report updates previous results to a mean follow-up period of 37 months. The initial results are essentially confirmed in that a mean PSA elimination half-life of 1.6 days in patients considered to be cured at least 24 months after prostatectomy provides additional useful information for predicting outcome in patients with potentially curable prostate cancer.

Adenocarcinoma↗
PubMed1993

Significance of androgen deprivation prior to radical prostatectomy, with special reference to prostate-specific antigen.

A total of 37 selected patients with clinical stage T2b or T3 prostate cancer received androgen deprivation prior to radical retropubic prostatectomy. A luteinizing hormone-releasing hormone (LHRH) analog alone was given to 15 individuals; 19 received an LHRH analog with flutamide. Three underwent bilateral orchiectomy instead of chemical castration. The duration of androgen deprivation prior to radical prostatectomy varied from 3 to 16 months, with 31 individuals undergoing induction therapy for 3-6 months. Three received androgen deprivation for more than 1 year. In all, 15 patients had clinical stage T2b disease and 22, stage T3 prostate cancer. The prostate size decreased approximately 30%-50% following induction therapy. Prostate-specific antigen (PSA) values decreased in all 19 instances where this was obtained. In all, 6 of 15 (40%) patients with clinical T2b lesions and 9 of 22 (41%) with clinical T3 tumors had a positive surgical margin; 5 (13%) had 1 or more positive lymph nodes. Androgen deprivation was continued following surgery in 13 cases. Only one patient received postoperative radiation therapy. After a mean follow-up period of 33 months, 35 (95%) patients are alive. Two patients died, one of poorly differentiated prostate cancer with subsequent metastasis and one of a myocardial infarction 33 months after surgery without showing any evidence of disease. Of 23 patients without postoperative adjuvant therapy, 6 (26.1%) progressed (PSA level, > 0.4 ng/ml). None of the patients who underwent adjuvant therapy progressed over a follow-up period of 6-75 months (mean, 38 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1980

Prevention of postoperative deep-vein thrombosis by low-dose heparin in open prostatectomy.

A double-blind trial was designed to investigate the efficacy of low-dose heparin in preventing deep-vein thrombosis (DVT) after open prostatectomy... The diagnosis of DVT was established by the 125I-fibrinogen test. The incidence of DVT was 39.4% in the control group (33 patients) and 9.7% in the heparin group (31 patients) (p less than 0.01). These results suggest that low-dose heparin effectively prevents DVT after open prostatectomy

Aged↗
PubMed1984

Prophylactic antibiotics in transurethral prostatectomy.

The study included 88 patients with sterile urine prior to transurethral prostatectomy. Forty-five received a preoperative dose of 2 g of cefotaxime (Claforan) and the remaining 43 were given 10 ml of 0.9% NaCl. The two groups did not differ in frequency of postoperative urinary infection (greater than 10(5) colonies per ml urine); 6 patients (13.3%) in the cefotaxime group had postoperative infections during hospital stay as compared to 8 patients (18.6%) in the control group (0.5 greater than p greater than 0.3). Those in the cefotaxime group who had infections were tested for resistance. They were all fully sensitive to cefotaxime except one, who was infected with enterococci. There was no growth of bacteria from either venous blood or bladder irrigating fluid taken during the operations. Nor were any serious complications observed in any of the patients. In view of the relatively low risk of infection and the few side effects of the infections that did occur, prophylactic treatment with an antibiotic is not indicated for transurethral prostatectomy in patients with sterile urine.

Aged↗
PubMed1978

Post-prostatectomy incontinence.

Urinary continence is maintained by the smooth-muscled system of the "internal sphincter". The striated external sphincter is not primarily responsible for continence. One of the chief functions of the external sphincter is the initiation of voluntary micturition. Its other functions are: random interruption of the urinary stream, reflex control during an increase in intra-abdominal pressure (such as coughing, sneezing, larghing, lifting) complete emp;ying of the urethra after micturition and stabilization of the posterior urethra in the urogenital diaphragm. After prostatectomy an intact external sphincter is important in order to support the smooth-muscled system which continues to be primarily responsible for continence to function as efficiently as possible. In approximately 90% of all postprostatectomy incontinences the external sphincter is intact and this cames a good prognosis following our correcture surgery without the need for prostheses. Only in rare post-prostatectomy incontinence cases (aprox. 10%) is the external sphincter also injured. Incontinence surgery according to our method has not been satisfactory in these cases.

Electromyography↗
PubMed1997

Evaluating radical prostatectomy specimens: therapeutic and prognostic importance.

The pathologic staging of prostate cancer involves determination of the anatomic extent and burden of tumor based on the best available data. Proper examination of radical prostatectomy specimens is critical in determining cancer stage, stratifying patient need for adjuvant treatment, and prediction of patient outcome. Differences exist in methods of handling and sampling specimens, although publication of practice protocols in recent years has led to convergence of opinion. In this report, we evaluate the current aspects of pathologic staging of prostate cancer and assessment of prostatectomy specimens. Recent international agreement on pathologic staging of prostate cancer should allow valid comparisons of surgical treatment from different institutions. The vanishing cancer phenomenon is also briefly discussed.

Carcinoma↗
PubMed1997

Radical prostatectomy as treatment for prostate-specific antigen-detected stage T1c prostate cancer.

The use of serum prostate-specific antigen (PSA) measurement as a method for early detection of prostate cancer has increased the detection of clinically and pathologically localized prostate cancer. Clinical stage T1c was introduced to describe cancers discovered on prostate biopsy as a result of an abnormal serum PSA level without a palpable prostatic abnormality on digital rectal examination. The majority of men with stage T1c tumors have significant disease warranting treatment. We report the results of anatomic radical retropubic prostatectomy as therapy for PSA-detected stage T1c prostate cancer in 340 men treated at a single institution. In all, 17 men (5%) have had a recurrence with 2.3 +/- 1.2 years of follow-up, 15 of whom have experienced an isolated biochemical PSA recurrence only. The overall actuarial biochemical PSA recurrence-free rate at 6 years is 87%, with pathologic stage being the best single indicator of the likelihood of progression. Although a longer period of follow-up is needed, this interim report suggests that these men can be cured by surgery at rates equal to or better than those of previously reported radical prostatectomy series.

Actuarial Analysis↗
PubMed1995

The impact of lower urinary tract symptoms on general health status and on the use of prostatectomy.

Our objective was to determine the extent to which lower urinary tract symptoms affect the general health status of men and contribute to the decision to undergo surgery. A cross-sectional population survey using postal questionnaires was conducted in the North West Thames health region, followed by a prospective cohort study of men undergoing prostatectomy (North West Thames and Oxford regions). The subjects in the first survey were 221 men aged 55 and over with previously reported mild, moderate or severe urinary symptoms; subjects in the second study were 388 men undergoing prostatectomy. Main outcome measures were self-reported symptom severity, bothersomeness and general health status (Nottingham Health Profile, Part 1). The response rate among eligible responders in the population survey was 85.7%. Increasing symptom severity was associated with worsening NHP scores for energy, emotional reactions, sleep and physical mobility (p < 0.01). Increasing bothersomeness of symptoms was associated with emotional reactions, sleep and pain (p < 0.05). Men undergoing surgery reported worse health status than men in the population with the same severity of symptoms as regards emotional reactions, energy and pain. For a given level of symptom severity, the impact of those symptoms on aspects of a man's general health status may be the determinant of seeking and undergoing surgery. Greater understanding of the factors that affect a man's response to his symptoms is needed in interpreting the decision to seek and accept treatment.

Aged↗
PubMed1978

Tumours of the urinary bladder accidentally diagnosed during prostatectomy.

By analysing 1472 prostatectomies, the authors have stated a coexistence of tumour of the bladder in 31 cases (2.11%). In 11 patients (0.75%) the tumours were accidentally diagnosed, as late as during the operation itself. Eight patients were operated transvesically. The tumour was diagnosed immediately after opening the bladder. The tumour was removed first and then the adenoma. Three patients were operated on according to Millin's method, their tumours having been detected only after enucleation of adenoma of the prostate. In five cases cancer of the bladder was diagnosed and in six papillary tumour of the bladder was found. The bladder cancers were treated by partial excision of the bladder or by deep electrocoagulation. The authors maintain that the small percentage of accidentally diagnosed tumours is no indication for a routine performance of cystoscopy in every case of adenoma of the prostate before intended prostatectomy.

Humans↗
PubMed1985

The evaluation of transcervical prostatectomy.

In a prospective study, transcervical prostatectomy was performed in 130 consecutive patients, aged between 52 and 92. Effort has been made to achieve a satisfactory haemostasis in the prostatic bed, in that continuous stitches along the posterior lip of the bladder neck seem to be more effective than interrupted stitches. The results of these two methods of haemostasis have been evaluated by the amount of blood transfused, duration of urethral catheter and stay in hospital after operation. The clinical value and the technical merits of this operation are discussed. The results compare favourably with other methods of prostatectomy.

Aged↗
PubMed1997

Antegrade techniques of collagen injection for post-prostatectomy stress urinary incontinence: the Washington University experience.

Treatment of sphincteric incontinence after radical retropubic prostatectomy remains a clinical challenge. Antegrade techniques of collagen injection are a relatively new method for treatment of post-prostatectomy incontinence. Early experience with this approach has demonstrated improved outcomes compared to the traditional retrograde technique. Overall response rates of 70% cure or significant improvement compare favorably with previously reported series. The theoretical advantages of this method include improved visualization of vesicourethral anastomosis and improved access to the bladder neck. Furthermore, suprapubic catheter drainage avoids the risks of collagen molding around the catheter. The use of a flexible cystoscope for this approach is a recent modification. The smaller diameter of the flexible cystoscope has facilitated access and reduced anesthetic requirements. This system affords unimpeded delivery of collagen to regions of the bladder neck where the submucosa accommodates the injectable agent. In addition, this modality allows more precise needle positioning to provide correct angle and depth of penetration into the submucosal plane. Short-term success rates of this procedure are encouraging and suggest that it may become the primary approach. While these antegrade techniques are more aggressive than the traditional retrograde approach, they are relatively simple and draw upon principles familiar to all urologists. It is hoped that the new flexible antegrade approach will further improve our results. Longer-term follow-up studies with larger numbers of patients will be required to see whether we can accomplish this goal.

Aged↗
PubMed1992

Prostatectomy in the very aged.

The number of very aged men who demand prostatectomy for benign disease is increasing. We have assessed surgery results in 79 patients operated during the last four years. Sixty-two underwent endoscopic and 17 open procedure. Mortality rate was 3.7%. Two patients died in the first week and one patient three weeks after surgery. Morbidity rate was 61% but did not significantly affect the final operative outcome. Operative success rate six weeks postoperatively was 87%, satisfactory for this age group. After detailed preoperative evaluation and postoperative care by specialized age care team, prostatectomy is safe, effective and involves low-cost treatment.

Age Factors↗
PubMed1995

The prognostic value of prostate specific antigen in the follow-up of patients after radical prostatectomy.

The authors compared the PSA levels in 19 patients who had undergone radical prostatectomy between 1986 and 1991. Measurements were done preoperatively, 3-4 weeks postoperatively and at the end of 1993. The increase of the average preoperative level corresponds to the stage of the disease (local, local advanced, metastatic lymph nodes). Patients with high preoperative PSA levels have a higher risk for progression, even if their postoperative PSA values are normal. While the predictive value of low PSA levels measured immediately after prostatectomy is small, high postoperative PSA levels are unfavourable prognostic signs.

Follow-Up Studies↗
PubMed1996

Comparing comorbid-illness indices assessing outcome variation: the case of prostatectomy.

OBJECTIVE: We investigated and compared the effects of three different comorbid indices on selection of procedure and outcome variation to determine which, if any, could be used for interpreting outcomes data. DESIGN: Retrospective cohort study. SETTING: Large multispecialty group practice. PATIENTS: Patients (aged 55-85 years) with residence in the United States who underwent a first-time prostatectomy for benign prostatic hyperplasia: 302 total; 253 transurethral procedures (TURF) versus 49 open procedures (OP). MEASUREMENTS AND MAIN RESULTS: The following indices were used to assess comorbid disease: Charison index (CI), index of coexistent disease (ICED), and Kaplan-Feinstein index (KFI). The main outcome measure was the five-year mortality rate. The unadjusted five-year mortality rates were 16% (40/ 253) for TURP and 4% (2/49) for OP; survival analysis revealed this difference to be marginally significant at the p = -05 level. In an effort to control for the effect of comorbidity, CI, ICED, and KFI were independently assessed: together with age, they each had similar effects in rendering the risk of death associated with procedure type insignificant. However, comorbidity, as derived with ICED (not CI or KFI), was identified as a confounding variable when assessing the five-year mortality rate after prostatectomy as ICED was associated with the procedure type (predictor variable) and the five-year mortality (outcome variable). CONCLUSION: Differences in the composition and scoring of comorbid indices may have important implications for interpreting outcomes data. Nevertheless, these results, together with those of previous studies, suggest that the reported increased mortality for patients undergoing TURP is probably due to case-mix differences.

Aged↗
PubMed1994

Preoperative staging and early postoperative complications in radical prostatectomy. Experiences in 35 cases.

It is already a textbook item that in patients with prostatic cancer stage T1-T2 N0M0 radical prostatectomy is the only curative treatment. Radical prostatectomy is indicated also for patients in stage T3 N0M0 who underwent antiandrogenic (Fugerel) treatment for 3 months with the aim of reducing tumour volume. In the following 35 cases will be scrutinized, with special regard to preoperative staging and early postoperative complications.

Humans↗