Radical Prostatectomy: Status and Opportunities for Improving Outcomes

Radical Prostatectomy: Sequelae in the Course of Time

Objective: Radical prostatectomy (RP) is a frequent treatment for men suffering from localized prostate cancer (PCa). Whilst offering a high chance for cure, it does not come without a significant impact on health-related quality of life. Herein we review the common adverse effects RP may have over the course of time. Methods: A collaborative narrative review was performed with the identification of the principal studies on the topic. The search was executed by a relevant term search on PubMed from 2010 to February 2021. Results: Rates of major complications in patients undergoing RP are generally low. The main adverse effects are erectile dysfunction varying from 11 to 87% and urinary incontinence varying from 0 to 87% with a peak in functional decline shortly after surgery, and dependent on definitions. Different less frequent side effects also need to be taken into account. The highest rate of recovery is seen within the first year after RP, but even long-term improvements are possible. Nevertheless, for some men these adverse effects are long lasting and different, less frequent side effects also need to be taken into account. Despite many technical advances over the last two decades no surgical approach can be clearly favored when looking at long-term outcome, as surgical volume and experience as well as individual patient characteristics are still the most influential variables. Conclusions: The frequency of erectile function and urinary continence side effects after RP, and the trajectory of recovery, need to be taken into account when counseling patients about their treatment options for prostate cancer.

Radical retropubic prostatectomy: a review of outcomes and side-effects

BACKGROUND

Radical prostatectomy (RP) is worldwide probably the most common procedure to treat localized prostate cancer (PC). Due to a more widespread use of Prostate-Specific Antigen (PSA) testing, patients operated today are often younger and have organ confined disease justifying a more preservative surgery. At the same time, surgical technique has improved resulting in lower risk of permanent side-effects. This paper aims to give an overview of results from modern surgery regarding cancer control and side-effects. A brief overview of the history is given.

MATERIAL AND METHODS

A literature research identified recently published papers focusing on outcome and side-effects after RP.

RESULTS

One large randomized study (SPCG-4) compared RP and watchful waiting (WW). The study showed that RP was superior to WW in preventing local progression (RR = 0.36), distant metastasis (RR = 0.65) and death from PC (RR = 0.65). Observational studies also show a better outcome for men treated with RP compared to WW. Peri-operative mortality after RP is low in most material around 0.1%. The risk of stricture of the vesico-urethral anastomosis has decreased with improved technique from historically 10-20% to a low incidence of around 2-9% today. Also the risk of incontinence has declined with improved technique. However, while the rates of severe incontinence is usually very low, as many as 30% still report light incontinence after long-term follow-up. Erectile dysfunction (ED) is still a frequent side-effect after RP. This risk is dependent on age, pre-operative sexual function, surgical technique and other risk factors for ED such as smoking, diabetes, etc. In selected subgroups the risk of ED is low. Inguinal hernia is a more recently described complication after open retropubic RP with a postoperative incidence of 15-20% within three years of surgery.

CONCLUSION

RP is an effective method to achieve cancer control in selected patients. With modern technique it is a safe procedure with a low risk of permanent side-effects except for ED.

Surgical treatment of localized prostate cancer

Radical retropubic prostatectomy (RRP) is the reference method for treatment of localised, organ confined prostate cancer. Since the introduction of nerve-sparing procedure for RRP in the 1980's, the operation has become widespread and is today one of the most common surgical procedures in Urology. In this overview the indications, operative procedure and side effects of RRP are briefly discussed.

A randomized clinical trial of suspension technique for improving early recovery of urinary continence after radical retropubic prostatectomy

OBJECTIVE

To evaluate, in a prospective, single-blind, randomized trial, the safety and efficacy of a suspension technique for improving early recovery of continence after radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

We randomly assigned 60 men with clinically localized prostate cancer to RRP; 30 were treated with the suspension technique and the remaining 30 were not. All patients had RRP by the same surgeon followed by early catheter removal on the third day after RRP. The primary outcome measures were the interval to recovery of continence, and the positive margin rates. The continence status was evaluated by a third party using validated questionnaires at baseline before RRP and at 4 and 7 days, and 2 weeks, 1, 3, 6 and 12 months after RRP.

RESULTS

The suspension technique resulted in significantly greater continence rates at 1, 3 and 6 months after RRP of 53% vs 20%, 73% vs 47% and 100% vs 83%. Kaplan-Meier curves also showed that patients in the suspension group had a significantly earlier recovery of continence than in the no-suspension group; the median (95% confidence interval) interval for recovery was 31 (12-74) days in the suspension group and 90 (65-150) days in the no-suspension group (log rank test, P = 0.002). The groups had no significant differences in their histological status.

CONCLUSIONS

The suspension technique had a significant effect on the earlier recovery of urinary continence within 6 months after RRP, without compromising the oncological outcome of RRP.

The development of a rat model of erectile dysfunction after radical prostatectomy: preliminary findings

OBJECTIVE

To develop a rat model of erectile dysfunction (ED) after cavernous nerve injury.

MATERIALS AND METHODS

Given the great similarity between the anatomical structure of the cavernous nerve in rats and humans, 24 rats underwent dissections and the cavernous nerves were identified with the aid of an operating microscope. Then the rats were randomized into two groups: sham-operated controls and a bilateral cavernous nerve section group. At 3 months after surgery, the rats were evaluated for their response to an apomorphine challenge.

RESULTS

The erectile response after an apomorphine challenge was normal in all the control rats, while there were no erections in the bilateral injured group.

CONCLUSION

The rat major autonomic ganglion and its cavernous nerve can be identified with the aid of a microscope. Rats are inexpensive and easy to handle, thus a good animal for developing an ED model of cavernous nerve injury. In the present study, the rats with cavernous nerve injury lost erectile capacity in a reliable and reproducible fashion. Because of the great similarity between the cavernous nerve of rats and humans, one may consider this technique as a reliable experimental model for studying ED after radical prostatectomy.

Standardizing cancer biomarkers criteria: data elements as a foundation for a database. Inflammatory mediator/M-CSF as model marker

The purpose of this position article was to design a set of criteria (data elements) for a wide range of cancer biomarkers (CBs) in an attempt to standardize biomarkers features through a common language as a foundation for a database. Data elements are described as a set of generic criteria, which should characterize nearly all biomarkers introduced in the literature. Data elements were extracted from the review of prominent features that biomarkers represent within various categories. The extracted characteristics of biomarkers produced a short list of shared and unique generic features such as biological nature and history; stage/phase of study; sensitivity and specificity; modes of action; risk assessment; validation status; technology, and recommendation status for diversified biomarkers. To tailor data elements on specific markers, a cytokine, such as macrophage-colony stimulating factor (M-CSF), which has been proposed as a 'potentially suitable biomarker' for diagnosis of ovarian, lung, breast, pancreatic, and colorectal cancers, was selected as a Model biomarker. Small scale clinical studies suggested the superior usefulness of M-CSF compared with traditional markers for cancer detection. A key criterion for selecting Model marker and tailoring data elements for detection of cancer was the comparison of data on its specificity and sensitivity with traditional markers. The design of data elements for standardizing CBs criteria is considered a Research Tool and a foundation for developing a comprehensive CBs database useful for oncology researchers for a wide range of biomarkers. Validation, integration and proper packaging, data visualization and recommendation of suitability of CBs, by a panel of experts, for technology development are important challenging next steps toward developing a reliable database, which would allow professionals to effectively retrieve and study integrated information on potentially useful markers; identify important knowledge gaps and limitations of data; and assess state of technologies and commercialization of markers at a point of need. Appropriate use of integrated information on biomarkers in clinical practices would eventually account for more cost-effective characteristics of an individual's state of health.

Time to Return to Work and Physical Activity Following Open Radical Retropubic Prostatectomy

PURPOSE

We identified factors that predict return to part-time and full-time work and resumption of unlimited physical activity following open radical retropubic prostatectomy.

MATERIALS AND METHODS

Between July 1, 2002 and February 28, 2005, 537 men with clinically localized prostate cancer underwent open radical retropubic prostatectomy, as performed by a single surgeon. Intraoperative, perioperative and postoperative parameters were recorded in real time and entered into a database. An assessment was made 1 and 3 months postoperatively regarding time to return to work and unrestricted physical activity.

RESULTS

Of the men 50% returned to part-time and full-time work, and unrestricted activity within 14, 21 and 30 days after discharge home, respectively. Patient age and hematocrit at hospital discharge significantly predicted return to part-time and full-time work, and unlimited physical activity. The number of days that the urinary catheter was indwelling was also associated with return to part-time work. Occupation (blue vs white collar) and marital status were also associated with return to full-time work. In the multivariate model a unit increase in hematocrit decreased the time to return to part-time and full-time work, and unrestricted physical activity by 0.50, 0.60 and 0.59 days, respectively. Men with discharge hematocrit greater than 32% were 1.57 (p = 0.059), 1.65 (p = 0.041) and 2.03 (p = 0.002) times more likely to return to part-time and full-time work, and unlimited activity before 14, 21 and 30 days, respectively. Overall models were developed that accounted for 9.4%, 14.0% and 4.0% of the time to return to part-time work, full-time work and unrestricted physical activity, respectively.

CONCLUSIONS

Efforts to increase discharge hematocrit by minimizing intraoperative blood loss or using preoperative blood management strategies and earlier removal of the urinary catheter have a favorable impact on the return to work and physical activity.

The effect of intracavernosal growth differentiation factor-5 therapy in a rat model of cavernosal nerve injury

OBJECTIVE

To determine whether the intracavernosal application of growth differentiation factor-5 (GDF-5) influences nerve regeneration and erectile function after cavernosal nerve injury in a rat model.

MATERIALS AND METHODS

Thirty-two male Sprague-Dawley rats were randomly divided into four equal groups: eight had a sham operation (uninjured controls), while 24 had bilateral cavernosal nerve crush. The crush-injury groups were treated at the time of injury with an impregnated collagen sponge implanted into the right corpus cavernosum. The sponge contained no GDF-5 (injured controls), 2 microg (low concentration), or 20 microg GDF-5 (high concentration). Erectile function was assessed by cavernosal nerve electrostimulation at 8 weeks. Midshaft penile tissue samples were histochemically evaluated for neuronal nitric oxide synthase (nNOS)-containing fibres in the dorsal penile nerve.

RESULTS

There was no erectile dysfunction in the uninjured control group, as shown by a mean (sem) maximal increase in intracavernosal pressure (ICP) of 149.5 (17.0) cmH(2)O on stimulation. By comparison, the ICP decreased in the injured control group, by 21.3 (6.7) cmH(2)O. After cavernosal nerve injury, the recovery of erectile function was greatest in the low-concentration GDF-5 group; the maximum ICP increase was 40.8 (13.3) cmH(2)O, vs 24.3 (5.9) cmH(2)O for 20 microg GDF-5. Histologically, the low-concentration group had significantly more nNOS-containing nerve fibres, at 163 (24.7), than the high-concentration group, at 76 (17.3), or injured controls, at 67 (23.8). By contrast, the uninjured controls had a mean of 538 (40.6) nerve fibres in the dorsal nerve.

CONCLUSION

Bilateral cavernosal nerve crush resulted in erectile dysfunction with accompanying neurological changes in the rat. The intracavernosal application of GDF-5 enhanced the recovery of erectile function and n-NOS nerve preservation, with a 2-microg dose giving the most promising results.

Outcomes for men younger than 50 years undergoing radical prostatectomy

OBJECTIVES

To compare the surgical outcomes after radical prostatectomy between men younger than 50 years and men 50 years old or older.

METHODS

Between October 1, 2000 and December 31, 2003, 790 men underwent open radical retropubic prostatectomy by a single surgeon. The intraoperative, perioperative, and postoperative parameters were recorded in real time and entered into a database. The outcomes were compared for 66 men younger than 50 years of age (group 1) versus 724 men who were 50 years old or older (group 2).

RESULTS

The pathologic stage, percentage of cancer in the surgical specimen, positive surgical margin rate, and Gleason score were not significantly different among the two age groups. No significant difference was found in the risk factors for prostate cancer between groups 1 and 2 (33.3% versus 28.9%, respectively; P = 0.63). The operative complications were exceedingly low in both groups. Of the men in groups 1 and 2, 93.3% and 97.1% achieved continence, respectively (P = 0.26). Of the potent men at baseline who underwent bilateral nerve-sparing prostatectomy, 100% of men in group 1 versus 81.4% in group 2 (P = 0.02) were having erections adequate for intercourse with or without phosphodiesterase-5 inhibitors or intracavernous injection therapy, as determined by direct patient interview. Of the men who underwent bilateral nerve-sparing radical retropubic prostatectomy, 78.3% of group 1 versus 62.6% of group 2 (P = 0.14) were potent with or without phosphodiesterase-5 inhibitors.

CONCLUSIONS

The preoperative and pathologic predictors of organ-confined disease and biochemical recurrence were similar in both age groups. The results of this study have demonstrated that radical retropubic prostatectomy can be performed with good results and low complication rates in men with localized prostate cancer who are younger than 50 years of age.

Contemporary evaluation of operative parameters and complications related to open radical retropubic prostatectomy

OBJECTIVES

To determine the impact of recent advances in surgical technique, management, and early detection on outcome after open radical retropubic prostatectomy.

METHODS

Between October 2000 and August 2002, 500 men with clinically localized prostate cancer underwent radical retropubic prostatectomy by a single surgeon (H.L.). One of the unique aspects of this prospective outcomes analysis was that both data acquisition and entry were conducted totally independent of the primary surgeon.

RESULTS

The mean operative and prostatectomy time was 142.9 and 65.2 minutes, respectively. A single ureteral injury was the only intraoperative complication. The overall incidence of pulmonary embolus and/or deep vein thrombosis was 0.4%. The overall risk of allogeneic transfusion was 4.6%. The mean length of hospital stay was 2.11 +/- 0.04 days. Of the catheters, 83.6% were removed by postoperative day 8. The positive surgical margin rate was 8%.

CONCLUSIONS

In the hands of experienced surgeons, outcomes after open radical prostatectomy are excellent. Laparoscopic and robotic prostatectomy must be compared with concurrent experiences with open radical prostatectomy.