Radical perineal prostatectomy: oncological outcome during a 20-year period

Techniques of robotic radical prostatectomy for the management of prostate cancer: which one, when and why

The advent of robotic assistance in surgery has completely revolutionized the surgical management of prostate cancer. It enables precise dissection and reconstruction in order to maximize oncological and functional outcomes. In many parts of the world, robot-assisted laparoscopic radical prostatectomy has evolved to become the surgical standard of care for localized disease, including in appropriately selected patients with high risk prostate cancer. Its role has also been expanded to encompass cytoreductive prostatectomy and salvage radical prostatectomy. As surgical expertise grows with robotic assistance, several novel and non-radical approaches have been developed to further mitigate treatment side effects. Patient characteristics, disease factors and surgeon expertise are important metrics for consideration when selecting the most appropriate technique for any given patient.

Androgen Ablation Therapy Does not Increase the Risk of Late Morbidity following 3D-conformal Radiotherapy of Organ-confined Prostate Cancer: The Experience of the European Institute of Oncology

Aims and Background

Androgen ablation therapy in conjunction with radiotherapy-neoadjuvant and adjuvant – has consistently been shown to be associated with improved biochemical and local control, whereas controversy still remains as regards its benefit in terms of overall survival. The objective of this study is to determine the impact of androgen ablation in combination to 3D-conformal radiotherapy on late treatment-related toxicity.

Methods

236 patients were treated with 3D-conformal radiotherapy to a total dose ranging from 70 and 78.6 Gy. Fifty-six patients did not receive any form of androgen ablation whereas 176 were given at least 3 months of neoadjuvant androgen ablation. Of these, 64 stayed on androgen ablation for a median time of 6 months post-radiotherapy. Acute toxicity was evaluated weekly during the course of treatment. Late toxicity was assessed at 3-months intervals during the follow-up. Toxicity was scored according to the RTOG criteria.

Results

The median follow-up was 24.6 months (range, 12-62). The incidence of late genitourinary toxicity was: 3% G2, 3.5% G3, 0.5% G4. The incidence of late gastrointestinal toxicity was: 12% G2, 2% G3, 1% G4. No association was observed between the use of androgen ablation and late treatment-related toxicity. High-risk patients who continued on androgen ablation long-term were not found to have an increased risk of developing late toxicity with respect to those who never had any form of androgen ablation or those only treated neoadjuvantly.

Conclusions

In our experience, the use of androgen ablation does not impact on late toxicity following high dose 3D-conformal radiotherapy for prostate cancer.

Rectal Injury in Radical Perineal Prostatectomy

Objective

To report our experience in treating patients with rectal injury with radical perineal prostatectomy.

Methods

Medical charts of 176 patients submitted to radical perineal prostatectomy from 1996 to 2005 were reviewed to identify rectal problems. A review of rectal injury in prostatectomy is provided.

Results

Of 176 patients who underwent radical perineal prostatectomy, 10 (5.7%) had rectal injury and 4 (2.3%) presented rectal fistula. Two (1.1%) patients were submitted to colostomy. We discuss how to avoid and treat the complications.

Conclusions

There is a real risk of rectal injury during radical perineal prostatectomy, particularly during the learning period or if the approach is not often performed. Fistula might occur, but colostomy is actually unnecessary and rare. A better understanding of the perineal anatomy and knowledge about the technique is recommended before practicing radical perineal prostatectomy.

Descriptive Technique and Initial Results for Robotic Radical Perineal Prostatectomy

OBJECTIVE

To minimize technical challenges of radical perineal prostatectomy (RPP), we conceived and applied the robotic approach to this technique in an aim to improve surgical applicability of RPP. Radical prostatectomy via the perineal route, avoiding the intra-abdominal cavity, has been shown to be oncologically safe, with excellent functional outcomes and a short hospital stay. We report our initial results with this novel approach.

MATERIALS AND METHODS

We performed the procedure in 4 patients. With the patient in the exaggerated lithotomy position, following a 3 cm perineal incision, the initial perineal dissection using Belt's approach is performed, followed by single port placement and docking of the robot.

RESULTS

The median age for patients was 64 years (60-69). Two patients had no rectum because of the abdominoperineal resection due to inflammatory bowel diseases. One of the other 2 patients had a surgical history of aborted robotic-assisted laparoscopic radical prostatectomy and 1 patient had no surgical history. There were no perioperative complications and the patients were discharged within 16-48 hours. Urethral catheter was removed within 10 days in 3 patients, and 3 weeks in 1 patient. Two patients were immediately continent when Foley was removed. The final pathology revealed focally positive margin in those 3 patients who had surgical histories and it was margin negative in the patient with native anatomy. All patients had undetectable prostate-specific antigen postoperatively.

CONCLUSION

RPP was successfully completed in 4 cases, applying a single port robotic perineal approach. Initial results are encouraging, with short hospital stay and minimal postoperative pain.

Differential post-prostatectomy cancer-specific survival of occult T3 vs. clinical T3 prostate cancer: Implications for managing patients upstaged on prostate magnetic resonance imaging

PURPOSE/OBJECTIVE

Long-term androgen deprivation therapy (ADT) was proven in randomized trials to be superior to short-term ADT for radiation-managed patients who have clinical T3 (cT3) disease, but it is unknown whether patients with T3 disease seen only on magnetic resonance imaging require similarly aggressive treatment. We attempted to study this issue by analogy by comparing the long-term post-prostatectomy survival of patients with cT3 disease versus cT1/T2 disease upstaged to pathologic T3 disease.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 60,165 men diagnosed with prostate adenocarcinoma between 1995 and 2002 who underwent prostatectomy. Prostate cancer-specific mortality (PCSM) was evaluated by stage after adjusting for grade, marital status, race, sex, year of diagnosis, and age.

RESULTS

The median follow-up was 10.5 years. Patients with cT1/T2 but pathologic T3a disease had significantly better 10-year PCSM than men with cT3 disease had (3.0% vs. 9.9%, adjusted hazard ratio [AHR] = 0.420, P<0.001), but they had worse PCSM than men with pathologic T2 disease had (3.0% vs. 0.91%, AHR = 2.53, P<0.001). Of patients with occult T3a disease, those with low-grade/intermediate-grade disease (Gleason score 7 or less) had a slightly higher 10-year PCSM when compared with those with pathologic T2 disease (1.34% vs. 0.91%, AHR = 1.69, P<0.001). Patients with cT1/T2 and pathologic T3b disease had similar PCSM as men presenting with cT3 disease (11.0% vs. 9.86%, AHR = 1.14 [0.862, 1.52], P = 0.353).

CONCLUSIONS

Patients with occult T3a disease had less than half the risk of PCSM as those with cT3 disease, and a subset of those men had similar risk as patients with pathologic T2 disease. Therefore, it is possible that radiation-managed patients with low-grade/intermediate-grade T3a disease by magnetic resonance imaging only might not require long-term ADT. However, patients with occult T3b or high-grade occult T3a disease have similar PCSM as that of those presenting with cT3 disease, so they should be treated as aggressively, including long-course ADT when managed by radiation.

[EVALUATION OF COMPLICATIONS OF RADICAL PERINEAL PROSTATECTOMY: EXPERIENCE OF 200 CASES]

OBJECTIVE

In recent years, robot-assisted laparoscopic prostatectomy has become widely used, and the perineal approach is utilized much less than before. However, radical perineal prostatectomy has some advantages with regard to operative complications. Here I evaluate 200 cases for which the perineal approach was used in the past 12 years.

MATERIALS AND METHODS

From 2000 to 2012, radical perineal prostatectomies were performed for 200 patients and their operative complications were evaluated. The mean age of the patients was 68.5 years, with a PSA of 9.4 ng/ml, and Gleason score of 6.9. Their clinical stages were T1 in 168 cases (84.0%), T2 in 26 (13.0%) and T3 in 6 (3.0%).

RESULTS

Mean operative time was 85 minutes, and estimated blood loss was 220.0 ml. The median time for urethral catheter indwelling was 7 days, and the admission term was 14 days. Operations were performed safely in patients with a BMI of more than 30 kg/m2. Lymphadenectomies from the same incision were performed in 20 cases and there were no lymph node metastases. Rectal injuries occurred in 7 cases (3.5%) with 100 cases of Blet's approach so I changed to Young's approach. With Young's approach I have not experienced any rectal injuries. Wound infection occurred in 4 cases (2.0%), hematoma in 2 (1.0%), anastomotic stricture in 1 (0.5%), inguinal hernia in 1 (0.5%), and transient lower extremity neurapraxia in 1 (0.5%). Postperineal pain after operation was tolerated using a donut cushion, though some pain relievers were needed in 20 cases (10.0%). Fecal incontinence occurred in 4 cases (2.0%) but was temporary.

CONCLUSIONS

With radical perineal prostatectomy it is easy to perform vesicourethral anastomosis, apical dissection and nerve sparing, and there are few complications such as inguinal hernia, anastomotic stricture and so on. In addition, there is less blood loss with this approach because the dorsal vein complex and pudendal arteries are out of sight. Therefore, radical perineal prostatectomy is suggested to be useful because of its safety, short operation time and low cost. Finally this procedure can be selected as the first choice for patients with past history of lower abdominal operation and obesity.

Location of positive surgical margin and its association with biochemical recurrence rate do not differ significantly in four different types of radical prostatectomy

Purpose

To analyze the location of the positive surgical margin (PSM) and its association with the biochemical recurrence (BCR) rate in cases of radical prostatectomy (RP) according to the type of surgery.

Materials and Methods

We retrospectively analyzed 1,880 cases of RP. Baseline characteristics were analyzed. Locations of the PSM were recorded in the four surgery groups as apex, anterior, posterolateral, and base and were analyzed by using chi-square test. The association of the location of the PSM with the BCR rate was analyzed by using Kaplan-Meier survival analysis according to the type of surgery, which included radical perineal prostatectomy (RPP, n=633), radical retroperitoneal prostatectomy (RRP, n=309), laparoscopic radical prostatectomy (LRP, n=164), and robot-assisted laparoscopic radical prostatectomy (RALRP, n=774).

Results

A PSM was found in a total of 336 cases (18%): 122 cases of RPP (18%), 67 cases of RRP (17%), 29 cases of LRP (17%), and 119 cases of RALRP (15%). The PSM rate did not differ significantly by surgical type (p=0.142). The location of the PSM was the apex in 136 cases (7.2%), anterior in 67 cases (3.5%), posterolateral in 139 cases (7.3%), and base in 95 cases (5.0%), and showed no significant difference according to surgical type (p=0.536, p=0.557, p=0.062, and p=0.109, respectively). The BCR rate according to the location of the PSM did not differ significantly for the four types of surgery (p=0.694, p=0.301, p=0.445, and p=0.309 for RPP, RRP, LRP, and RALRP, respectively).

Conclusions

The location of the PSM seemed to be unrelated to type of RP. There was no significant correlation between the BCR rate and the location of the PSM for any of the RP types.

Case for resurgence of radical perineal prostatecomy in Indian subcontinent

Introduction:

Radical perineal prostatectomy was the first surgery described for prostatic carcinoma (Young, 1904) but it lost its eminent status after Walsh's description in 1982 of anatomic radical retropubic prostatectomy followed by the enthusiasm in laparoscopy and now robotics. It made resurgence after it was realized in early 1990s that the pelvic lymph node dissection is needed only in selected cases. Last decade witnessed over 80 publications addressing the results and advances in the perineal approach. Strangely, centres from the subcontinent have chosen to ignore this resurgence. We describe our early experience with the technique in 35 patients and present the case for its more widespread usage.

Patients and Methods:

Thirty five patients of clinically localized carcinoma prostate were operated by perineal route in our institution from December 2006 onwards. All patients had serum prostate specific antigen levels less than 10 ng/ml.

Results:

Operating time was 2 to 3.5 hours (mean 2.5 hours). Rectal injury occurred in three patients but was closed primarily in all and none required a colostomy. Mean duration of hospital stay was four days. The disease was organ confined in 25(71%). Positive margins were seen in 5(14%) patients. Biochemical recurrence occurred in 17% patients at one year. Seventy six percent patients had achieved continence at one year.

Conclusions:

As the world is taking note of radical perineal prostatectomy again, with a very small learning curve, minimal invasion and good oncological control urologists from Indian subcontinent should also embrace this procedure in view of the relative limited resources available.

Experience with radical perineal prostatectomy in the treatment of localized prostate cancer

Radical perineal prostatectomy is an alternative to the retropubic, robotic-assisted or the laparoscopic approach and it is one of the oldest surgical procedures for prostate cancer, but its use has declined over the past 30 years. The desire for lower morbidity, short hospital stay, and decreased costs has resulted in a renaissance of radical perineal prostatectomy. The combination of low morbidity, short hospital stay, and low economic costs brought to a renaissance of radical perineal prostatectomy.

Risk factors for biochemical recurrence following radical perineal prostatectomy in a large contemporary series: a detailed assessment of margin extent and location

OBJECTIVES

The implications of positive surgical margin (PSM) extent and location during radical perineal prostatectomy (RPP) have not been assessed in a contemporary series. We aimed to examine the incidence, location, and extent of PSM as well as their impact on biochemical recurrence (BCR) following RPP.

MATERIALS AND METHODS

A total of 794 patients underwent RPP by a single surgeon between June 1993 and August 2010. Covariates included age, pathologic T stage, pathologic Gleason sum, preoperative PSA, prostate volume, PSM extent, and location. Life table, Kaplan-Meier, and Cox regression analyses assessed predictors of BCR following RPP.

RESULTS

PSM were recorded in 162 patients (20.4%); of these, 83 (51.2%) were focal (≤ 1 mm) whereas 79 (48.8%) were broad (>1 mm). Location of PSM was anterior 10.5%, posterior or lateral 14.8%, bladder neck 23.5%, apical 32.1%, and multifocal 19.1%. At a median follow-up of 54 months, the 5-year BCR-free probability was 90.8% in patients with negative margins, 77.5% in patients with focal PSM, and 47.5% in patients with broad PSM. On multivariable analyses adjusted for age, pathologic T stage, pathologic Gleason sum, preoperative PSA, and prostate volume, broad PSM, (HR = 3.49, P < 0.001) as well as anterior (HR = 3.77, P = 0.003), bladder neck (HR = 2.25, P = 0.01) and multifocal (HR = 3.55, P < 0.001) PSM were independent predictors of BCR.

CONCLUSIONS

In this study, we present oncologic outcomes following RPP in a large contemporary cohort of patients undergoing RPP. In adjusted analyses, broad and anterior PSM carried the highest risk of recurrence after RPP.

A critical analysis of the long-term impact of radical prostatectomy on cancer control and function outcomes

CONTEXT

The optimal management strategy for men with newly diagnosed clinically localized prostate cancer remains a matter of debate. Numerous series have reported cancer control and quality-of-life (QoL) outcomes following treatment with radical prostatectomy (RP).

OBJECTIVE

Critically review published oncologic and functional outcomes after RP, and evaluate factors associated with these outcome measures.

EVIDENCE ACQUISITION

A review of the literature was performed using the Medline and Web of Sciences databases. Relevant reports published between 1980 and 2011 identified using the keywords prostate cancer, radical prostatectomy, prostate-specific antigen, biochemical recurrence, incontinence, and erectile dysfunction were reviewed and summarized.

EVIDENCE SYNTHESIS

Cancer control rates following RP largely depend on the definition of treatment efficacy. While up to 40% of men have been reported to experience postoperative biochemical recurrence on long-term follow-up, death from prostate cancer has been noted in <10% of men at 15 yr after surgery in contemporary series. For men with high-risk disease, surgery affords pathologic staging, thereby facilitating the selective application of secondary therapies, and has been associated with decreased mortality risk versus radiation in retrospective series. Reported functional outcomes after surgery, particularly urinary continence and erectile dysfunction, have varied greatly to date. These assessments have been limited by nonstandardized reporting methodology. The use of robot-assisted radical prostatectomy has increased in recent years, and while follow-up is thus far short, available data do not suggest the superiority of either approach in terms of functional or oncologic outcomes.

CONCLUSIONS

RP is associated with excellent long-term cancer control. Continued efforts to conduct prospective assessments of postoperative functional outcomes are necessary using validated QoL instruments. The importance of surgical approach will also require further study, incorporating comparative oncologic, functional, and economic data.

Salvage radiotherapy for patients with PSA relapse following radical prostatectomy: issues and challenges

A progressively rising level of serum prostate specific antigen (PSA) after radical prostatectomy (RP) invariably indicates the recurrence of prostate cancer. The optimal management of patients with post-RP PSA relapse has remained uncertain due to a wide variability in the natural course of post-RP PSA relapse and the inability to separate a recurrent disease confined to the prostate bed from that with occult distant metastasis. Management uncertainty is further compounded by the lack of phase III clinical studies demonstrating which therapeutic approach, if any, would prolong life with no significant morbidity. Radiotherapy has been the main therapeutic modality with a curative potential for patients with post-RP PSA relapse. This review article depicts issues and challenges in the management of patients with post-RP PSA relapse, presents the literature data for the efficacy of salvage radiotherapy, either alone or in combination of androgen ablation therapy, and discusses future directions that can optimize treatment strategies.

[Seminal vesicle sparing radical perineal prostatectomy]

BACKGROUND

The early and mid-term oncological and functional results of a seminal vesicle sparing modification of perineal nerve sparing radical prostatectomy (SV-RPP) was compared to the classical perineal (RPP) and retroperitoneal (RRP) approaches.

MATERIALS AND METHODS

From July 2003 to December 2007, 702 radical prostatectomies (417 RPP, 285 RRP) were performed by 3 surgeons (mean follow-up 17 months, range 0-48 months). RPP was chosen under the following conditions: PSA<10 ng/ml, Gleason sum<7 and volume<50 ml. A seminal vesicle sparing technique (SV-RPP) was used in 47% of the RPPs.

RESULTS

With a significantly shorter average operation (OR) time (SV-RPP 90 min, RPP 144 min, RRP 165 min), transfusion rate (SV-RPP 3%, RPP 9.1%, RRP 11.9%) and rate of anastomotic leaks at day 10 (SV-RPP 6.4%, RPP 10.3%, RRP 27.8%) the pT2 positive surgical margin rate with SV-RPP (3.4%) was significantly lower than with RPP (9.6%) and RPP (8.4%). For pT2-R0 tumors PSA relapse>0.2 ng/ml occurred in 12.5%, 13.6% and 8.2%, respectively (not significant). Continence rates (0-1 pad) for SV-RPP were significantly better compared to RPP and RRP after 4 weeks (59.3%, 41.0% and 45.4%, respectively) and 12 months (95.7%, 86.4% and 86.8%, respectively)

CONCLUSIONS

SV-RPP represents an improved perineal technique with respect to intraoperative and postoperative complications whilst maintaining an oncological outcome comparable to RPP and RRP. Leaving seminal vesicles in situ did not result in increased PSA relapse rates.

Neoadjuvant hormonal deprivation for patients undergoing radical prostatectomy

The purpose of this study is to evaluate the therapeutic effect of radical prostatectomy combined with preoperative neoadjuvant hormonal ablation therapy for prostate cancer (PCa). In this study, a total of 31 patients with local PCa underwent radical prostatectomy; of these, 12 patients underwent preoperative hormonal deprivation with a combination of goserelin and flutamide for a period of 5.6 months. Data regarding clinical characteristics were compared between the neoadjuvant therapy and radical prostatectomy groups. A total of 31 patients received pelvic lymph node clearance, and the rate of positive lymph nodes was 12.9% (4/31). Serum prostate-specific antigen (PSA) was 8.9 +/- 1.2 microg L(-1) after the neoadjuvant therapy and 0.4 +/- 0.3 microg L(-1) one month after the radical prostatectomy. There were significant differences in the positive surgical margins, seminal vesicle invasion and lymph node metastasis between the neoadjuvant therapy group (n = 12) and the radical prostatectomy group (n = 19, P < 0.01). The resulsts indicates that preoperative hormonal deprivation induced by goserelin and flutamide can decrease clinical and pathological staging, but assessment of its influence on long-term prognosis requires further study.

Impact of nerve sparing technique on patient self-assessed outcomes after radical perineal prostatectomy

PURPOSE

We investigated the impact of nerve sparing technique on erectile function, urinary continence and health related quality of life after radical perineal prostatectomy using a validated self-assessment questionnaire.

MATERIALS AND METHODS

The Expanded Prostate Cancer Index Composite questionnaire was administered preoperatively and at defined intervals after surgery to 265 patients who underwent radical perineal prostatectomy at 2 institutions between January 2001 and December 2004. Of these patients 153 (57.7%) and 112 (42.3%) underwent nonnerve sparing and nerve sparing approaches, respectively. Kaplan-Meier analysis was used to determine time to recovery of erectile function (erections firm enough for intercourse) and urinary continence (0 pads per day).

RESULTS

Median patient age was 60.6 years. Median followup was 15 months. In multivariate analysis preoperative erectile function (p = 0.005) and preservation of the neurovascular bundle (p = 0.018) were independent predictors of earlier recovery of erectile function, with hazard ratios of 2.3 (95% CI 1.2-4.6) and 4.0 (95% CI 1.5-10.3), respectively. Median time to recovery of urinary continence was 4.8 months in the nerve sparing group and 6.1 months in the nonnerve sparing group (p = 0.001). In multivariate analysis nerve sparing technique (p = 0.001, HR 1.4, 95% CI 1.1-1.9) and age (p = 0.012, HR 1.7, 95% CI 1.3-2.2) were independent predictors of recovery of continence.

CONCLUSIONS

This analysis suggests that nerve sparing radical perineal prostatectomy is associated with improved recovery of urinary continence and favorable health related quality of life scores and, therefore, should be considered a viable alternative to other nerve sparing approaches.

Natural history of biochemical recurrence after radical prostatectomy: risk assessment for secondary therapy

PURPOSE

A persistently elevated or rising serum level of prostate-specific antigen (PSA) after radical prostatectomy is indicative of recurrent prostate cancer. The natural history of PSA-defined biochemical recurrence (BCR) is highly variable. While a rising PSA level universally antedates metastatic progression and prostate cancer-specific mortality (PCSM), it is not a surrogate for these endpoints. Thus, the management of patients with BCR is controversial.

METHODS

A literature review was conducted to determine the incidence and natural history of BCR, prognostic factors for clinical progression (CP), and the available evidence supporting local or systemic salvage therapy for these patients.

RESULTS

BCR is best defined as two successive PSA levels > or =0.4 ng/ml, as this correlates most accurately with CP. PSA doubling time (PSA-DT) and prostatectomy Gleason score are the variables that best predict the development of distant metastasis and PCSM. Prognostic models based on these and other variables are useful for assessing the need for salvage therapy and the anticipated outcome following local salvage therapy. A treatment algorithm for managing patients with post-prostatectomy BCR was devised.

CONCLUSIONS

Management of patients with BCR after prostatectomy continues to be a complex and challenging issue. Improved methods for risk stratification allow for identification of patients who require treatment. Furthermore, these methods aid in determination of the pattern of disease recurrence, thereby guiding treatment modality. Randomized trials are essential to determine the value of local or systemic salvage therapy strategies in this patient population.

The anatomic radical perineal prostatectomy: an outcomes-based evolution

OBJECTIVE

Radical prostatectomy is the most effective treatment for localized prostate cancer. With increasing use of minimally invasive treatment methods, clinical outcomes are becoming important assessment tools to compare one option to another. Perineal prostatectomy is modified to incorporate contemporary surgical ideas, including preservation of cavernosal nerve bundles, sphincteric urethra at the prostatic apex, and the bladder neck.

METHODS

Objective parameters and physician-reported clinical outcomes are collected prospectively on 704 consecutive patients undergoing radical perineal prostatectomy (RPP) by one surgeon. The technique described herein is the current state of evolution of RPP. The enclosed digital video is edited from two recent nerve-sparing RPPs.

RESULTS

Freedom from prostate-specific antigen (PSA) detectability by stage is 94.5%, 80.0%, and 81.5% for organ-confined, specimen-confined, and margin-positive disease with actual 5-yr follow-up. Margins are positive in 18% of cases. By 1, 3, 6 mo and 1 yr, 52%, 71%, 85%, and 94% of the men are free from using pads. Although >97% of nerve-spared patients have spontaneous erections, >80% can penetrate to complete intercourse.

CONCLUSIONS

This method of prostatectomy is able to achieve complete cancer resection while preserving urinary and sexual function in the majority of men presenting with clinically localized prostate cancer. The simplicity and minimally invasive nature of this procedure contribute to a short recovery and low overall cost of therapy. The anatomic RPP is a cost-efficient, outcome-effective minimally invasive method of treating men with localized prostate cancer.

Prostatectomie périnéale

There is a lack of prospective randomised trials comparing the efficacy of the different techniques for treating localised prostate cancer. Consequently, selecting one rather than the other appears very difficult. Even radical prostatectomy is controversial regarding its best approach--perineal, retropubic or laparoscopic. The perineal route was the first to be undertaken, and it was dropped out due to the need of performing obturator lymphadenectomy by a separate approach. Widespread use of prostate-specific antigen as a screening method has enabled to diagnose prostate cancer at its early stages, when the potential for lymphatic dissemination is low, which enables to obviate Lymphadenectomy in most patients. This was a promoting circumstance to use the perineal route in radical prostatectomies. In this article we discuss the perineal radical prostatectomy surgical technique, its indications, and its advantages and disadvantages as compared to other approaches.

High-intensity focused ultrasound therapy for clinically localized prostate cancer

The efficacy of high-intensity focused ultrasound (HIFU) used for the treatment of localized prostate cancers has been demonstrated over the past decade. We present our early results after HIFU used as a single session in patients with clinically localized prostate cancer. A total of 58 patients were treated using the Ablatherm HIFU device with or without transurethral resection of the prostate (TURP). HIFU failure was defined as the presence of a cancer remnant on repeated biopsies or three consecutive increases in the prostate-specific antigen (PSA) >/=1.0 ng/ml. The mean follow-up was 14 months (range, 6-21 months). After HIFU treatment, 78% of patients had a decreased PSA level to <0.5 ng/ml within 3 months. The median value of the last PSA was 0.6 ng/ml and the median nadir PSA was 0.2 ng/ml. The success rates of HIFU were 85, 77 and 47% in low-, intermediate- and high-risk groups, respectively. The HIFU failure rate was closely associated with clinical stage, presence of cancer on TURP chips and nadir PSA on univariate analysis. However, the only significant predictor for HIFU failure was the nadir PSA value by multivariate Cox regression analysis. The operation-related complications were minimal. Although both the period and number of patients were limited to evaluate the clinical efficacy, HIFU appears to be a safe and effective treatment option in selected patients with prostate cancer.

Radical perineal prostatectomy for treatment of localized prostate cancer in obese and nonobese patients: A matched control study

OBJECTIVES

To compare the perioperative outcomes of severely obese and nonobese patients undergoing radical perineal prostatectomy (RPP).

METHODS

A cohort of 71 severely obese patients, as defined by a body mass index of 35 kg/m2 or more, who underwent RPP between 1992 and 2003 was retrospectively identified. These patients were matched by age, American Society of Anesthesiologists class, and year of surgery to a cohort of 71 nonobese patients (body mass index less than 25 kg/m2). Statistical testing was performed to compare the estimated blood loss, transfusion requirements, and complication rates (primary endpoints), as well as the length of surgery, intraoperative anesthesia requirements, postoperative hematocrit level, length of stay, and surgical margin status (secondary endpoints).

RESULTS

The mean body mass index +/- standard deviation of patients in the obese and nonobese group was 38.9 +/- 4.7 and 22.9 +/- 1.6 kg/m2 (P = 0.001), respectively. Patients were similar with regard to baseline characteristics. Obese and nonobese patients did not demonstrate significant differences in mean estimated blood loss (571 +/- 391 and 494 +/- 317 mL, respectively; P = 0.06), transfusion rates (2.8% and 7.0%, respectively; P = 0.45), or positive surgical margin rates (14.1% and 9.9%, respectively; P = 0.22). The overall complication rates were significantly different at 16.9% and 7.0% (P = 0.03).

CONCLUSIONS

Severely obese patients undergoing RPP had blood transfusion rates similar to those of the nonobese patients. Obese RPP patients were at increased risk of surgical and anesthesia-related perioperative complications, many of which might be avoidable. Specifically, efforts should be directed toward preventing the development of lower extremity neurapraxia by minimizing the operative time and optimizing patient positioning.

Changes in quality of life in first year after radical prostatectomy by retropubic, laparoscopic, and perineal approach: Multi-institutional longitudinal study in Japan

OBJECTIVES

To investigate the health-related quality of life of patients who underwent radical prostatectomy performed using retropubic, laparoscopic, and perineal approaches.

METHODS

A total of 218 men who underwent retropubic prostatectomy, 65 who underwent laparoscopic prostatectomy, and 66 who underwent perineal prostatectomy were enrolled in our survey. A baseline interview was conducted before treatment. Follow-up interviews were conducted in person at scheduled study visits 1, 3, 6, and 12 months after surgery. We measured two validated questionnaires that assessed the general and disease-specific health-related quality of life.

RESULTS

The retropubic group reported substantial deterioration in physical limitations, emotional limitations, social function, and bodily pain at 1 month. The perineal group reported less bodily pain just after surgery than the retropubic and laparoscopic groups. After 6 months, however, no significant differences were found among the three groups. Postoperative urinary function remained substantially lower than the baseline level in every treatment group. Each approach with a nerve-sparing procedure showed a similar recovery profile of urinary function postoperatively. The perineal group reported no significant difference in bowel function compared with the other two groups. All of the groups continued to have decrements in sexual function.

CONCLUSIONS

The results of this study have demonstrated that retropubic, laparoscopic, and perineal prostatectomy have differences in the recovery of general and disease-specific quality of life in the early postoperative period. When performed by an experienced surgeon, the retropubic, laparoscopic, and perineal approaches appear to be equivalent in terms of health-related quality of life.

Evaluation and Management of Prostate-specific Antigen Recurrence After Radical Prostatectomy for Localized Prostate Cancer

A radical prostatectomy has been established as one of the standard management options for localized prostate cancer. However, a substantial proportion of patients who undergo a radical prostatectomy develop prostate-specific antigen (PSA) recurrence which is commonly defined as a PSA cut-off point value of 0.2 ng/ml. Although the management of PSA recurrence after radical prostatectomy may depend on the site of recurrence, it is quite difficult to identify the recurrent lesion accurately based on the currently available imaging technology. Patients who have surgical margin involvement or a Gleason score < or =7 based on the radical prostatectomy specimens, who do not have nodal or seminal vesicle involvement, and who develop a PSA recurrence >1-2 years after surgery with a doubling time of >1 year, and whose pre-treatment PSA is < 1.0-1.5 ng/ml are considered to benefit from local treatment with at least 64 Gy of salvage radiotherapy. Patients with different characteristics are considered to have distant metastases or both local lesions and distant metastases, and thus may be candidates for hormonal manipulation rather than radiotherapy. Since local recurrent lesions are considered to be quite small at the early stage of PSA recurrence, hormonal manipulation may be sufficient to prevent disease progression instead of radiotherapy. However, the optimal type and timing of hormonal manipulation remain to be elucidated. As a result, no consensus regarding the treatment for PSA recurrence after radical prostatectomy has yet been reached.

Contemporary appraisal of radical perineal prostatectomy

PURPOSE

In the age of minimally invasive surgery there has been renewed interest in the perineal approach for the surgical treatment of prostate cancer. We reviewed recent publications regarding radical perineal prostatectomy (RPP) in an effort to define its role in the current management of localized prostate malignancy. At the same time we reviewed the relevant perineal anatomy and surgical approach necessary to perform this operation.

MATERIALS AND METHODS

We performed a review of the literature with respect to RPP and included our own extensive experience with this operation, emphasizing patient selection, the current role of pelvic lymph node dissection, surgical anatomy, oncological outcomes and complications.

RESULTS

RPP is an effective treatment for localized adenocarcinoma of the prostate with oncological outcomes similar to those of the retropubic technique. In comparison to RRP, patients undergoing RPP have less postoperative discomfort, more rapid return of bowel function, more rapid return to work and a decreased transfusion rate. In addition, RRP is now often performed with cavernous nerve sparing. Prostate specific antigen screening has made the rate of lymph node metastasis low enough to omit lymphadenectomy in many cases.

CONCLUSIONS

There is still a role for RPP in the treatment of localized prostate cancer. Erectile dysfunction after nerve sparing and incontinence rates are similar to those of RRP. In addition, it is less morbid then RRP without being as technically challenging as laparoscopic radical prostatectomy.

Vattikuti Institute prostatectomy, a technique of robotic radical prostatectomy for management of localized carcinoma of the prostate: experience of over 1100 cases

Advances in surgical techniques, technology, and surgeons' skills have allowed robot-assisted radical prostatectomy to be an option in the management of organ-confined prostate cancer. The goals of the VIP technique are to cure cancer, preserve urinary continence, preserve potency, and decrease morbidity, along with the benefits of a minimally invasive surgery and excellent cosmesis. VIP is nearly equal to traditional retro-pubic prostatectomy, with certain outstanding advantages.

The cooperative prostate cancer tissue resource: a specimen and data resource for cancer researchers

PURPOSE

The Cooperative Prostate Cancer Tissue Resource (CPCTR) is a National Cancer Institute-supported tissue bank that provides large numbers of clinically annotated prostate cancer specimens to investigators. This communication describes the CPCTR to investigators interested in obtaining prostate cancer tissue samples.

EXPERIMENTAL DESIGN

The CPCTR, through its four participating institutions, has collected specimens and clinical data for prostate cancer cases diagnosed from 1989 onward. These specimens include paraffin blocks and frozen tissue from radical prostatectomy specimens and paraffin blocks from prostate needle biopsies. Standardized histopathological characterization and clinical data extraction are performed for all cases. Information on histopathology, demography (including ethnicity), laboratory data (prostate-specific antigen values), and clinical outcome related to prostate cancer are entered into the CPCTR database for all cases. Materials in the CPCTR are available in multiple tissue formats, including tissue microarray sections, paraffin-embedded tissue sections, serum, and frozen tissue specimens. These are available for research purposes following an application process that is described on the CPCTR web site (www.prostatetissues.org).

RESULTS

The CPCTR currently (as of October 2003) contains 5135 prostate cancer cases including 4723 radical prostatectomy cases. Frozen tissues, in some instances including patient serum samples, are available for 1226 cases. Biochemical recurrence data allow identification of cases with residual disease, cases with recurrence, and recurrence-free cases.

CONCLUSIONS

The CPCTR offers large numbers of highly characterized prostate cancer tissue specimens, including tissue microarrays, with associated clinical data for biomarker studies. Interested investigators are encouraged to apply for use of this material (www.prostatetissues.org).

Gleason score and pretreatment prostate-specific antigen in survival among patients with stage D2 prostate cancer

Although multiple studies have addressed the prognostic importance of tumor differentiation in patients with clinically localized prostate cancer, few data are available in patients with metastatic disease. We evaluated and compared survival data in two groups of men with Whitmore stage D2 metastatic prostate cancer initially treated with hormonal therapy. A series of 76 patients with D2 metastatic disease were evaluated and treated at the National Cancer Institute (NCI) in conjunction with an additional cohort of 141 patients from the Louisiana State University School of Medicine (LSU). Pathological specimens were classified according to the Gleason score. Fifty-two (25%) of the combined NCI/LSU specimens had a Gleason score of 6 or less, 71 (34%) had a value of 7, and remaining 87 (41%) had scores between 8 and 10. The median PSA at the time of diagnosis for the NCI patients was 294.2 ng/ml. Time to treatment failure was defined as the time that a greater than 50% increase above nadir PSA was noted. In neither group was Gleason score correlated with overall survival. There was no association between the time to progression following hormone therapy and primary tumor Gleason score. The PSA concentration at the time of diagnosis was not correlated with the Gleason score for the NCI patients; however, there was an inverse correlation between pretreatment PSA level and time to progression following hormonal ablation. Gleason score does not appear to impact survival in metastatic prostate cancer. PSA as a marker of the biological behavior in metastatic disease may also be limited. These findings should be reevaluated in larger, better matched cohorts. Novel techniques such as serum proteomics, microarrays, and metastatic cell isolation methods may better predict outcome in advanced prostate cancer.

Laparoscopic radical prostatectomy: review and assessment of an emerging technique

BACKGROUND

Several recent reports have affirmed the feasibility of the laparoscopic approach for radical prostatectomy. In this review, we discuss the morbidities associated with this technique and compare outcomes and convalescence with standard open radical prostatectomy.

METHODS

We reviewed all currently published data on laparoscopic radical prostatectomy and our series of 45 robotic-assisted radical prostatectomies and compared them to several landmark series of open retropubic and perineal radical prostatectomies.

RESULTS

Although the initial series reported long operating times, these times have been significantly reduced in more recent series. Data on blood loss, convalescence, impotence, and incontinence rates have also been promising.

CONCLUSIONS

Although follow-up has been short thus far, laparoscopic radical prostatectomy has been shown to be similar to open radical prostatectomy in several areas.

SPECIFIC COMPLICATIONS OF RADICAL PERINEAL PROSTATECTOMY: A SINGLE INSTITUTION STUDY OF MORE THAN 600 CASES

PURPOSE

Although groups at several institutions have long experience with radical perineal prostatectomy (RPP), only few reports of larger series describe associated complications, mostly without reporting management options in detail. We analyzed specific perioperative and postoperative complications of the perineal approach and management strategies thereof.

MATERIALS AND METHODS

The medical records of 630 patients who underwent RPP between January 1997 and May 2003 were retrospectively reviewed in regard to complications and their management. Median followup was 8 months (range 1 to 68).

RESULTS

Major complications requiring open surgical intervention were noted in 11 patients (1.7%) for a total surgical revision rate of 2.4% (15 of 630). Two patients with persistent urinary fistula required fistula excision and closure. Two patients with a rectocutaneous fistula needed temporary diverting colostomy. Three patients with a combined urinary and fecal fistula were treated with protective colostomy, fistula excision and the interposition of a tunica vaginalis graft. No further morbidity was observed in these patients. In 7 patients a subvesical hematoma was drained surgically, including 3 mentioned in whom a hematoma expanded into the urethral anastomosis. Minor complications, which could be successfully managed conservatively or with endoscopic interventions only, developed in 124 patients for a total rate of 19.7%. In the long term 9% of the patients experienced postoperative de novo changes in stool habits after RPP but only 2.7% reported distressing anal sphincter incompetence.

CONCLUSIONS

RPP is a safe and reproducible procedure with low major complication and reintervention rates even in a training center setting with many involved surgeons. A subvesical hematoma should be revised early since it can be the origin of subsequent major complications.

Relative influence of Gleason score and pretreatment PSA in predicting survival following brachytherapy for prostate cancer

PURPOSE

To evaluate 10-year survival rates after prostate brachytherapy and to assess the relative importance of pretreatment prostate-specific antigen (PSA) and Gleason score in predicting cancer death.

MATERIALS AND METHODS

A retrospective review was performed on all patients treated with permanent brachytherapy for stage T1 or T2 primary prostate cancer at a single institution from December 1988 through June 30, 1998. The study cohort consisted of 1266 patients with a median follow-up of 4.1 years and a maximum of 12.6 years. Actuarial survival and cause-specific survival rates were calculated as the primary endpoints, and compared at 5 and 10 years. Groups studied consist of PSA<or=4, PSA 4.1-10, and PSA>or=10 as well as Gleason 2-4, 5-6, and 7-10. Multivariate and univariate analysis were performed looking at stage, grade, PSA, and risk group as variables.

RESULTS

The median age at the time of treatment was 73 years and at the time of analysis 603 patients were known to be alive. Overall survival is 38% at 10 years, however most deaths were unrelated to prostate cancer. Cause specific survival at 5 and 10 years is 98% and 87%. Both grade (>or=Gleason 7) and PSA (>or=10 ng/ml) predict adversely for cancer death within 10 years. Patients with low grade or PSA at presentation reveal prostate cancer-specific survival of 91% and 98%, respectively. By contrast, men with high grade or high PSA presentation have survival of 66% and 69% at 10 years. In multivariate analysis, the presence of one of these adverse features carries a hazard ratio of cancer death of 4.7 and 6.4, while the presence of multiple risk factors places patients in an unfavorable risk group with a hazard ratio of 27.

CONCLUSIONS

Biochemical disease-free survival is a useful tool to assess prostate cancer treatments and is predicted based on established pretreatment risk groups. Long-term cancer-specific survival is ultimately a more important endpoint. Brachytherapy is reported here to be an excellent therapeutic alternative for selected early stage patients with prostate cancer. This is based on 10-year cause specific survival, which may also be predicted by stage, grade, PSA, and risk group. Of these, the risk group remains the most powerful parameter to identify those patients at highest risk of biochemical failure and death from prostate cancer.

Prostate cancer patients' support and psychological care needs: Survey from a non-surgical oncology clinic

While there are numerous uncertainties surrounding prostate cancer's detection and treatment, more research focusing on the psychological needs of prostate patients is required. This study investigated the support and psychological care needs of men with prostate cancer. Patients were approached during urological oncology clinics and asked to complete the: Support Care Needs Survey (SCNS), Support Care Preferences Questionnaire, EORTC QLQ-C30 (Version 3) Measure plus Prostate Module, and the Hospital Anxiety and Depression Scale (HADS). Of the 249 patients meeting study entry criteria, there was an 89% response rate resulting in a cohort of 210 patients. The data showed that significant unmet need exists across a number of domains in the areas of psychological and health system/information. The more commonly reported needs were 'fears about cancer spreading (44%),' 'concerns about the worries of those close to you (43%),' and 'changes in sexual feelings (41%).' Half of all patients reported some need in the domain of sexuality, especially men younger than 65 years. Needs were being well met in the domain of patient care and support. A significant number of patients reported having used or desiring support services, such as information about their illness, brochures about services and benefits for patients with cancer (55%), a series of talks by staff members about aspects of prostate cancer (44%), and one-on-one counselling (48%). Quality of life (QoL) was most negatively impacted in those who: were < or =65 years old, had been diagnosed within one year, or had metastatic disease. Men < or =65 had decreased social functioning, greater pain, increased sleep disturbance, and were more likely to be uncomfortable about being sexually intimate. Patients recently diagnosed had increased fatigue, more frequent urination, greater disturbance of sleep, and were more likely to have hot flushes. Those with advanced disease scored lower on 12 out of 15 QoL categories. PSA level had no effect on QoL or anxiety/depression scores. Men with advanced disease had greater levels of depression and those < or =65 years old were more likely to be anxious. Although most men with prostate cancer seem to function quite well, a substantial minority report areas of unmet need that may be targets for improving care.

[Functional results of various surgical techniques for radical prostatectomy]

Radical prostatectomy for the treatment of prostate cancer can be performed by various techniques using a retropubic, perineal, or laparoscopic approach. Besides tumor control, the postoperative urinary continence rates and potency rates impact patients' quality of life after radical prostatectomy. This paper shows the results of our own center and compares the data in the literature regarding functional results of radical prostatectomy with respect to various operative techniques.

Radical prostatectomy, external beam radiotherapy <72 Gy, external beam radiotherapy ≥72 Gy, permanent seed implantation, or combined seeds/external beam radiotherapy for stage T1–T2 prostate cancer

PURPOSE

To review the biochemical relapse-free survival (bRFS) rates after treatment with permanent seed implantation (PI), external beam radiotherapy (EBRT) <72 Gy (EBRT <72), EBRT > or =72 Gy (EBRT > or =72), combined seeds and EBRT (COMB), or radical prostatectomy (RP) for clinical Stage T1-T2 localized prostate cancer treated between 1990 and 1998.

METHODS AND MATERIALS

The study population comprised 2991 consecutive patients treated at the Cleveland Clinic Foundation or Memorial Sloan Kettering at Mercy Medical Center. All cases had pretreatment prostate-specific antigen (iPSA) levels and biopsy Gleason scores (bGSs). Neoadjuvant androgen deprivation for < or =6 months was given in 622 cases (21%). No adjuvant therapy was given after local therapy. RP was used for 1034 patients (35%), EBRT <72 for 484 (16%), EBRT > or =72 for 301 (10%), PI for 950 (32%), and COMB for 222 patients (7%). The RP, EBRT <72, EBRT > or =72, and 154 PI patients were treated at Cleveland Clinic Foundation. The median radiation doses in EBRT <72 and EBRT > or =72 case was 68.4 and 78.0 Gy, respectively. The median follow-up time for all cases was 56 months (range 12-145). The median follow-up time for RP, EBRT <72, EBRT > or =72, PI, and COMB was 66, 75, 49, 47, and 46 months, respectively. Biochemical relapse was defined as PSA levels >0.2 for RP cases and three consecutive rising PSA levels (American Society for Therapeutic Radiology Oncology consensus definition) for all other cases. A multivariate analysis for factors affecting the bRFS rates was performed using the following variables: clinical T stage, iPSA, bGS, androgen deprivation, year of treatment, and treatment modality. The multivariate analysis was repeated excluding the EBRT <72 cases.

RESULTS

The 5-year bRFS rate for RP, EBRT <72, EBRT > or =72, PI, and COMB was 81%, 51%, 81%, 83%, and 77%, respectively (p <0.001). The 7-year bRFS rate for RP, EBRT <72, EBRT > or =72, PI, and COMB was 76%, 48%, 81%, 75%, and 77%, respectively. Multivariate analysis, including all cases, showed iPSA (p <0.001), bGS (p <0.001), year of therapy (p <0.001), and treatment modality (p <0.001) to be independent predictors of relapse. Because EBRT <72 cases had distinctly worse outcomes, the analysis was repeated after excluding these cases to discern any differences among the other modalities. The multivariate analysis excluding the EBRT <72 cases revealed iPSA (p <0.001), bGS (p <0.001), and year of therapy (p = 0.001) to be the only independent predictors of relapse. Treatment modality (p = 0.95), clinical T stage (p = 0.09), and androgen deprivation (p = 0.56) were not independent predictors for failure.

CONCLUSION

The biochemical failure rates were similar among PI, high-dose (> or =72 Gy) EBRT, COMB, and RP for localized prostate cancer. The outcomes were significantly worse for low-dose (<72 Gy) EBRT.

Inverse association between prostatic polyunsaturated fatty acid and risk of locally advanced prostate carcinoma

BACKGROUND

An effect of fatty acids has been implicated in men with advanced-stage prostate carcinoma and in men who have died of the disease. To evaluate the influence of fatty acids in men with prostate carcinoma at earlier stages, the authors examined the relation between prostatic concentrations of fatty acids and locally advanced prostate carcinoma in men with clinically organ-confined disease.

METHODS

Fatty acids were measured by capillary gas chromatography in fresh, nonmalignant prostate tissue specimens collected during surgery from 196 men undergoing radical prostatectomy for localized prostate carcinoma. Two-sided, two-sample Student t tests compared mean concentrations in men with extraprostatic disease (pT3-4N0-1M0) with control men with organ-confined disease. Logistic regression accounted for clinical stage, prostate-specific antigen level, Gleason sum, and other factors.

RESULTS

Percent total prostatic polyunsaturated fatty acid (PUFA) was found to be inversely associated with risk of locally advanced prostate carcinoma (n=52) (odds ratio [OR]=0.93, 95% confidence interval [95% CI], 0.87-0.99; P=0.035). Risk of seminal vesicle involvement accounted for this association (OR=0.86, 95% CI, 0.78-0.95; P=0.003). Percent omega-3 fatty acid (eicosapentanoic + docosahexanoic acids) and percent arachidonic acid also were found to be inversely related to the risk of seminal vesicle involvement (OR=0.52, 95% CI, 0.30-0.90; P=0.02; and OR=0.84, 95% CI,; 0.75-0.95; P=0.005, respectively).

CONCLUSIONS

Prostatic PUFA levels appear to influence the risk of locally advanced prostate carcinoma in men with clinically organ-confined disease. This association may be mediated through the immune system.

When to diagnose and how to treat prostate cancer in the ‘not too fit’ elderly

The appropriate management of elderly patients diagnosed with prostate cancer remains controversial. In order to provide guidelines as to when aggressive local treatment may be indicated, we provide estimates of the long-term probability of death from prostate cancer and other competing causes in patients of 70 years of age or older, who underwent radical surgery in the form of radical perineal prostatectomy for clinically non-metastatic disease. In this study, a total of 484 patients with an age of 70 or above who underwent radical perineal prostatectomy between 1970 and 2000 comprised a retrospective cohort of patients with clinically organ confined prostate cancer. Of these patients, 461 patients (95.3%) had a minimum follow-up of half a year and were included in the analysis. The median age was 73 years (range 70-81 years) and the median follow-up was 5.4 years. Overall 115 men died during the follow-up period with 49.6% of deaths attributable to prostate cancer. The median time to cancer-associated death was 17.5 years and the median time to death of any cause 11.6 years. When the likelihood of death from prostate cancer as a function of Gleason score was estimated, the 10-year cancer-associated death rates of patients with Gleason scores of 2-6, 7 and 8-10, were 15.2, 25.2 and 40.2%, respectively. In the subset of patient with margin positive disease the estimated likelihood of a cancer-associated death was 45.3% after 10 years. While the median time to cancer-associated death for margin positive patients with a Gleason score of 2-6 was not reached, patients with a Gleason score of 7 and 8-10 experienced median cancer-associated survival times of 9.6 and 7.6 years, respectively. In conclusion, Gleason score is a strong predictor of the likelihood of prostate cancer related death in elderly patients. Patients with a given Gleason score and a projected life expectancy of at least 10 years may be at similar risk of dying of prostate cancer as younger patients.

Radical perineal prostatectomy: cost efficient, outcome effective, minimally invasive prostate cancer management

OBJECTIVE

Localized prostate cancer is a common disease for which minimally invasive treatment methods are being explored. Perineal prostatectomy, as a historical open procedure, is modified to incorporate contemporary surgical ideas. There is relatively little in the literature regarding modern adaptations of perineal prostatectomy. This method of anatomic radical perineal prostatectomy has been developed to accomplish a minimally invasive method of achieving goals of disease control and preservation of genito-urinary functions.

METHODS

Prospective outcome data is accumulated on 508 consecutive radical perineal prostatectomies by a single surgeon. Pathologic stage and PSA detectability are measures of cancer control. Pad use and ability to complete intercourse measure urinary and sexual function. General complications and other outcome measures are evaluated.

RESULTS

Freedom from PSA detectability by pathologic stage is 96.3%, 79.4%, and 69.4% for organ confined, specimen confined and margin positive in the absence of seminal vesical invasion with an average 4 years follow up (3-114 months). Margins are positive in 18% of cases. The average cancer size is 9.4g and 36% of cases have extracapsular invasion. By the first, third, sixth months and one year, 38%, 65%, 88% and 96% are free of pad use and report being dry. While over 80% of nerve-spared patients enjoy the return of spontaneous erectile function, the men with bilateral nerve preservation note earlier and more complete return of function. There are no cardiopulmonary complications or deaths. Transfusions occurred in 1%, none in the past 400 cases. Average total hospital charges are USD$4889.00 in 1999 and 2000. Anterior urethral strictures, anastomotic strictures and fecal urgency/stress flatus occur 2%, 2% and 2-4%, respectively.

CONCLUSIONS

This method of prostatectomy is able to achieve complete cancer resection while preserving urinary and sexual function as well as laparoscopic or retropubic prostatectomy. The simplicity and minimally invasive nature of this procedure contribute to a short recovery and low overall cost of therapy. The anatomic radical perineal prostatectomy is a cost-efficient, outcome effective minimally invasive method of treating men with localized prostate cancer.

A longitudinal assessment of bowel related symptoms and fecal incontinence following radical perineal prostatectomy

PURPOSE

Recent studies have suggested an increased incidence of fecal incontinence following radical perineal prostatectomy. We provide a prospective and longitudinal assessment of bowel related symptoms of patients undergoing radical perineal prostatectomy.

MATERIALS AND METHODS

A total of 78 patients who underwent radical perineal prostatectomy between January 1 and December 31, 2001 and had a minimal followup of 6 months were included in the analysis. Patient information was obtained from the chart and the bowel domain specific questions of a validated quality of life questionnaire, the Expanded Prostate Cancer Index Composite. The questionnaire was administered to the candidates preoperatively, at 4 weeks following surgery and subsequently at 3-months intervals. A mean bowel function, bother and summary health related quality of life score was calculated at each interval. The duration of new or worsened symptoms with respect to baseline was evaluated using Kaplan-Meier analysis.

RESULTS

Symptoms of involuntary stool leakage and rectal urgency were reported by 11.5% (9 of 78) and 19.2% (15) of patients preoperatively. While all bowel related symptoms transiently increased following surgery, rectal urgency was the most persistent symptom, yet normalized in more than 90% of patients within 9 1/2 months. Compared to individual baseline 15.4%, 7.7%, 5.1% and 3.9% of patients reported worsened symptoms of fecal incontinence after 3, 6, 9 and 12 months, respectively. In the subset of 69 patients who denied preoperative fecal incontinence the incidence of involuntary stool leakage was 2.9% by 12 months following radical perineal prostatectomy. Of 10 patients 9 recovered individual health related quality of life score by 6 months after prostatectomy.

CONCLUSIONS

Longitudinal assessment of self-reported questionnaire data suggests that fecal incontinence and bowel related symptoms are more prevalent following radical perineal prostatectomy compared to baseline, yet resolve in the majority of patients with time in the early postoperative period.

Phase III trial comparing whole-pelvic versus prostate-only radiotherapy and neoadjuvant versus adjuvant combined androgen suppression: Radiation Therapy Oncology Group 9413

PURPOSE

This trial tested the hypothesis that combined androgen suppression (CAS) and whole-pelvic (WP) radiotherapy (RT) followed by a boost to the prostate improves progression-free survival (PFS) by 10% compared with CAS and prostate-only (PO) RT. This trial also tested the hypothesis that neoadjuvant and concurrent hormonal therapy (NCHT) improves PFS compared with adjuvant hormonal therapy (AHT) by 10%.

MATERIALS AND METHODS

Eligibility included localized prostate cancer with an elevated prostate-specific antigen (PSA) < or = 100 ng/mL and an estimated risk of lymph node (LN) involvement of 15%. Between April 1, 1995, and June 1, 1999, 1,323 patients were accrued. Patients were randomly assigned to WP + NCHT, PO + NCHT, WP + AHT, or PO + AHT. Failure for PFS was defined as the first occurrence of local, regional, or distant disease; PSA failure; or death for any cause.

RESULTS

With a median follow-up of 59.5 months, WP RT was associated with a 4-year PFS of 54% compared with 47% in patients treated with PO RT (P =.022). Patients treated with NCHT experienced a 4-year PFS of 52% versus 49% for AHT (P =.56). When comparing all four arms, there was a progression-free difference among WP RT + NCHT, PO RT + NCHT, WP RT + AHT, and PO RT + AHT (60% v 44% v 49% v 50%, respectively; P =.008). No survival advantage has yet been seen.

CONCLUSION

WP RT + NCHT improves PFS compared with PO RT and NCHT or PO RT and AHT, and compared with WP RT + AHT in patients with a risk of LN involvement of 15%.

Localized prostate cancer: radiation or surgery?

The treatment of localized prostate cancer remains controversial because of the lack of conclusive well-controlled or randomized studies comparing outcomes of radiotherapy to outcomes of radical prostatectomy. A comparison of different therapies should include issues of cancer control, morbidity, quality of life (QOL), salvage of primary treatment failures, late effects, and cost. The available data suggest that these two modalities provide similar rates of cancer control at 10 years, and that except for the youngest patients, choice of therapy should be based on toxicity and QOL issues.

Serum prostate-specific antigen and survival after external beam radiotherapy for carcinoma of the prostate

OBJECTIVES

To evaluate the significance of pretreatment prostate-specific antigen (pPSA) levels as a predictor of overall survival simultaneously with previously established prognostic factors. The pPSA level is a major predictor of treatment failure after radiotherapy and surgery, but to date has not been shown to predict survival.

METHODS

This analysis was based on data from 927 patients with clinically localized prostate cancer treated with radiotherapy alone between 1987 and 1998. These patients were stratified into four prognostic risk groups, and multivariate analysis was used to determine the independent impact of pPSA level on PSA failure, progression-free survival (death from any cause after PSA failure), and overall survival (death from any cause).

RESULTS

In a multivariate analysis simultaneously considering the prognostic risk group, a pPSA level greater than or equal to 20 ng/mL was associated with a higher risk of PSA failure and worse progression-free and overall survival.

CONCLUSIONS

The pPSA level is an independent predictor of survival in patients initially treated with radiotherapy alone.

Defining the ideal cutpoint for determining PSA recurrence after radical prostatectomy. Prostate-specific antigen

OBJECTIVES

To determine the ideal cutpoint for defining prostate-specific antigen (PSA) recurrence after radical prostatectomy (RP). Although various cutpoints have been used, a recent study suggested that 0.4 ng/mL may be the most appropriate.

METHODS

A retrospective survey of 358 men undergoing RP at the West Los Angeles Veterans Affairs Medical Center between 1991 and 2001 was undertaken. The 3-year and 5-year risk of PSA recurrence was estimated by Kaplan-Meier analyses using various cutpoints of postoperative PSA to define recurrence: greater than 0.1, greater than 0.2, greater than 0.3, greater than 0.4, and greater than 0.5 ng/mL. The 1 and 3-year risk of PSA progression after a detectable PSA level (PSA rising to a higher cutpoint) was evaluated for each definition of PSA recurrence using Kaplan-Meier analyses. Multivariate analysis using a Cox proportional hazards model was used to determine the clinical variables that were significant independent predictors of PSA recurrence at each cutpoint.

RESULTS

For patients with a detectable postoperative PSA value from 0.11 to 0.2 ng/mL, the 1 and 3-year risk of PSA progression was 64% (95% confidence interval [CI] 46% to 82%) and 93% (95% CI 74% to 99%), respectively. For patients with a PSA value from 0.21 to 0.3 ng/mL, the 1 and 3-year risk of PSA progression was 86% (95% CI 69% to 97%) and 100% (95% CI 87% to 100%), respectively. The use of higher PSA cutpoints to define recurrence resulted in a lower 5-year risk of PSA recurrence. The 5-year risk of PSA recurrence using a greater than 0.1 ng/mL cutpoint resulted in a 43% (95% CI 36% to 50%) risk of recurrence compared with only 23% (95% CI 18% to 30%) for a greater than 0.5 ng/mL cutpoint. In multivariate analysis, PSA and biopsy Gleason score were significant independent predictors of biochemical recurrence, regardless of the definition of PSA recurrence used (P <or=0.002).

CONCLUSIONS

PSA and biopsy Gleason score were significant predictors of biochemical failure, regardless of the definition of failure used. However, the definition of PSA recurrence dramatically affected the perceived success of therapy. Patients with a postoperative PSA value greater than 0.2 ng/mL are at very high risk of developing an additional rise in PSA. On the basis of this finding, a PSA value greater than 0.2 ng/mL is an appropriate cutpoint to define PSA recurrence after RP.