Radical retropubic prostatectomy for localised prostatic carcinoma: a clinical and pathological study of 201 cases

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.

Single‐dose orally administered quinolone appears to be sufficient antibiotic prophylaxis for radical retropubic prostatectomy

OBJECTIVE

To evaluate a new prophylaxis routine, which was introduced at our clinic in December 1998, comprising a single oral dose of antibiotic given prior to radical retropubic prostatectomy (RRP).

MATERIAL AND METHODS

A total of 60 men scheduled to undergo RRP were included in a prospective study and received antibiotic prophylaxis in the form of a single oral dose of quinolone. Cultures were made from the tip of the catheter and from urine sampled at the time of extraction as well as 1 and 2 weeks post-extraction. The outcome of this prospective study of 60 men was then compared to the total numbers of patients operated on in 1998 (n = 103) and 1999 (n = 140) by means of a retrospective analysis of clinical files.

RESULTS

No cases of sepsis occurred. Two weeks after catheter removal, 15/60 patients had persisting bacteriuria. No other signs of infection were detected. Six patients developed a stricture of the anastomotic area during follow-up (mean duration 18.9 months). When the study group was compared to all patients operated on in 1998 and 1999 no increases in the incidence of anastomotic strictures or serious infections or in the length of hospitalization could be detected.

CONCLUSION

A single dose of antibiotic given before RRP appears to be sufficient prophylaxis.

Microvessel density and regulators of angiogenesis in malignant and nonmalignant prostate tissue

The aim of this study was to investigate the relationship between microvessel density (MVD), positive and negative angiogenic factors, and established prognostic factors in prostate cancer (PC), and, to clarify the effect of angiogenic factors to angiogenesis. The vascularization of neoplastic, non-neoplastic prostate tissue was determined by CD34 immunostaining. Angiogenetic mediators VEGF, bFGF, TSP-1, and p53 were studied by immunohistochemistry. Neovascularization and p53, VEGF, and TSP-1 expressions of tumorous tissue were higher than non-tumorous tissue. The bFGF expression in these tissues was not different. The p53 expression was not correlated with the expressions of VEGF, bFGF, and TSP-1 in PC. Our results demonstrate a significant increase in MVD, VEGF, TSP-1, and p53 expressions in prostate tumorigenesis. The pretreatment sPSA was the only parameter demonstrating significant correlation with tumor grade and may have a value in the prediction of aggressive tumor behavior in PC.

Adrenergic drugs for urinary incontinence in adults

BACKGROUND

Adrenergic drugs have been used for the treatment of urinary incontinence. However, they have generally been considered to be ineffective or to have side effects which may limit their clinical use.

OBJECTIVES

To determine the effectiveness of adrenergic agonists in the treatment of urinary incontinence in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (January 2002) and the reference lists of relevant articles. Date of the most recent searches: January 2002.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which include an adrenergic agonist drug in at least one arm for adults with urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Collaboration Handbook.

MAIN RESULTS

Fifteen randomised trials were identified, which included 832 women, of whom 506 received an adrenergic drug (phenylpropanolamine in 11 trials, Midodrine in two and Clenbuterol in another two). Of these, six were crossover trials. No trials included men. The limited evidence suggested that an adrenergic agonist drug is better than placebo in reducing number of pad changes and incontinence episodes, as well as improvement in subjective symptoms. The drugs also appeared to be better than pelvic floor muscle training in two small trials, possibly reflecting relative acceptability of the treatments to women but perhaps due to differential withdrawal of women from the trial groups. There was not enough evidence to evaluate the use of higher compared to lower doses of adrenergic agonists nor the relative merits of an adrenergic agonist drug compared with oestrogen, whether used alone or in combination.

REVIEWER'S CONCLUSIONS

There was weak evidence to suggest that use of an adrenergic agonist is better than placebo treatment. There was not enough evidence to assess the effects of adrenergic agonists when compared to or combined with other treatments. Patients using adrenergic agonists may suffer from minor side effects, only occasionally leading them to stop treatment. Rare but serious side effects such as cardiac arrhythmias and hypertension have been reported, however.

Prostate-specific antigen for prostate cancer staging in a population-based register

OBJECTIVE

Previous studies have shown a relationship between serum prostate-specific antigen (PSA) level and prostate tumour volume. Reports based on selected case series have also indicated that serum PSA may be used for staging, although a varying prevalence of metastasizing tumours complicates the interpretation of these studies. In order to determine the accuracy of the serum level of PSA in predicting the presence of metastases we performed a prospective cohort study of a geographically defined population of men with prostate cancer.

METHODS

Serum level of PSA and the results of investigations for regional lymph node and distant metastases were recorded for all 8328 men with prostate cancer registered in the Swedish National Prostate Cancer Register 1996-1997.

RESULTS

The prevalence of lymph node metastases among men who had undergone lymph node exploration was 4%, 16% and 33% for well, moderately and poorly differentiated tumours. The corresponding prevalence of distant metastases was 12%, 30% and 48%. With serum PSA <20 ng/ml as a cut-off point the negative likelihood ratios for well and moderately differentiated tumours were found to be 0.47 and 0.45 for lymph node metastases and 0.24 and 0.18 for distant metastases, resulting in post-test probabilities >92% for the exclusion of metastases. In men with poorly differentiated tumours, the negative likelihood ratio would need to be even lower to safely exclude disseminated disease.

CONCLUSION

For well to moderately differentiated tumours, further investigations to assess the presence of metastases may be omitted with no great risk for understaging if serum PSA <20 ng/ml.

The treatment of prostate cancer: an overview of current options

PURPOSE

The purpose of this report is to discuss the current treatment options available to the patient with prostate cancer in all stages of the disease.

OVERVIEW

With the exception of skin cancer, prostate cancer is the most common cancer in men in the United States. Most patients in the current era will present with organ-confined disease, amenable to curative treatment. Treatment for organ-confined disease includes watchful waiting, radical prostatectomy, radiation therapy, and cryosurgery in selective cases. Hormone therapy is the cornerstone of treatment of patients with advanced prostate cancer. There is no curative treatment for hormone-refractory prostate cancer.

CLINICAL IMPLICATIONS

The availability of several therapeutic options for localized prostate cancer warrants careful consideration when planning treatment with curative intent. Patients need to be active participants in decision making, and they must be aware of the benefits and possible complications of the different types of treatment. Patients with advanced prostate cancer need to be aware that hormone treatment will provide temporization and palliation in the majority of cases. Hormone-resistant prostate cancer is refractory to most forms of conventional and experimental therapy.

Impact of different variables on the outcome of patients with clinically confined prostate carcinoma: prediction of pathologic stage and biochemical failure using an artificial neural network

BACKGROUND

The advent of advanced computing techniques has provided the opportunity to analyze clinical data using artificial intelligence techniques. This study was designed to determine whether a neural network could be developed using preoperative prognostic indicators to predict the pathologic stage and time of biochemical failure for patients who undergo radical prostatectomy.

METHODS

The preoperative information included TNM stage, prostate size, prostate specific antigen (PSA) level, biopsy results (Gleason score and percentage of positive biopsy), as well as patient age. All 309 patients underwent radical prostatectomy at the University of Colorado Health Sciences Center. The data from all patients were used to train a multilayer perceptron artificial neural network. The failure rate was defined as a rise in the PSA level > 0.2 ng/mL. The biochemical failure rate in the data base used was 14.2%. Univariate and multivariate analyses were performed to validate the results.

RESULTS

The neural network statistics for the validation set showed a sensitivity and specificity of 79% and 81%, respectively, for the prediction of pathologic stage with an overall accuracy of 80% compared with an overall accuracy of 67% using the multivariate regression analysis. The sensitivity and specificity for the prediction of failure were 67% and 85%, respectively, demonstrating a high confidence in predicting failure. The overall accuracy rates for the artificial neural network and the multivariate analysis were similar.

CONCLUSIONS

Neural networks can offer a convenient vehicle for clinicians to assess the preoperative risk of disease progression for patients who are about to undergo radical prostatectomy. Continued investigation of this approach with larger data sets seems warranted.

Prostate carcinoma trends in three counties in Sweden 1987-1996: results from a population-based national cancer register. South-East Region Prostate Cancer Group

BACKGROUND

To detect changes in the incidence rate and management of prostate carcinoma, all cases of the disease diagnosed in the southeast region of Sweden between 1987-1996 were recorded.

METHODS

The register is based on Swedish personal registration numbers, thereby minimizing the number of dropouts. All cases of prostate carcinoma detected in the southeast region have been recorded according to a defined protocol that has been updated successively to match recent views regarding the disease. To ensure a high number of presented cases, the National Cancer Register was checked for missing cases.

RESULTS

Six thousand seven hundred eighty-two cases of prostate carcinoma were registered in the region between 1987-1996. The age-adjusted incidence rate reached a peak in 1993, followed by a slight decrease. The mean age at diagnosis throughout the period was 74.2 years, with a peak age of 74.8 years in 1992. The number of incidental tumors followed the development of the number of transurethral resections of the prostate performed in the region, with a peak in 1991. The percentage of patients receiving gonadotropin-releasing hormone (GnRH) analogues increased from 3.9% to 37.8% whereas the percentage of patients treated with orchiectomy decreased from 40.0% to 12.8% and the percentage of those treated with radical prostatectomy decreased from 11.1% to 2.5%.

CONCLUSIONS

A diminishing pool of latent tumors may explain the decreasing incidence rate and lower age at diagnosis observed after 1993. Orchiectomy is rapidly being superseded by GnRH analogues. In contrast to trends reported in the U.S., the percentage of men with prostate carcinoma undergoing total prostatectomy appears to be declining in Sweden.

Treatment of prostate cancer: watchful waiting, radical prostatectomy, and cryoablation

Current advances in diagnostic modalities and screening has lead to diagnosis of prostate cancer at an earlier stage (the so-called "stage shift" phenomenon), making primary treatments of localized disease of extreme importance in management. Therapeutic modalities include conservative management, radical prostatectomy, external beam radiotherapy, and newer techniques such as cryoablation surgery and brachytherapy. This review will focus on the non-radiation, non-hormonal primary treatment of localized prostate cancer and discuss the popularity and success of "watchful waiting," radical surgery, and cryoablation along with their advantages and disadvantages. These treatments will be compared to the qualities of an ideal treatment, which include cost effectiveness, efficacy, convenience of administration, tolerance by patients, low morbidity and mortality, and minimal impact on quality of life.

Vascular density is a predictor of cancer-specific survival in prostatic carcinoma

BACKGROUND

Microvessel density has been shown to give prognostic information in a variety of solid tumors, but its role in prostatic carcinoma needs further elucidation.

METHODS

Intratumoral density of von Willebrand factor-positive microvessels was assessed in 98 cases of prostatic carcinoma, diagnosed at transurethral resection of the prostate (TURP) between 1975-1983, using two methods: 1) volume density of microvessels and 2) vascular count in the 2-3 most vascularized fields.

RESULTS

Volume density and vascular counts were highly correlated. In Kaplan-Meyer analysis, mean cancer-specific survival time for patients with a vascular count < 135 was significantly longer than for patients with a vascular count > 135 (P = 0.0064). The same results applied to patients with WHO grade II tumors (P = 0.01). Excluding metastasis in a multivariate analysis, both tumor stage and vascular count had an independent predictive value for cancer-specific survival in patients with WHO grade II tumors.

CONCLUSIONS

Microvessel density may predict cancer-specific survival in prostatic carcinoma.

Radiotherapy of localised prostate cancer. Analysis of late treatment complications. A prospective study

PURPOSE

To describe the late side-effects of radical radiotherapy of prostatic carcinoma and to analyse how pretreatment and treatment-related factors contribute to the toxicity.

MATERIALS AND METHODS

184 patients have regularly been followed after terminated radical external beam radiotherapy treatment (70 Gy) for a mean of 46 (range 24-96) months. For registration of toxicity a modified RTOG scale was used. The Cox regression model was used for multivariate analysis.

RESULTS

37% of the patients had no late side-effects at all. Mild complications were reported by 53%, mainly gastrointestinal (42%) and urogenital (23%). A persistent improvement of the mild toxicity was seen in nearly half of the patients with gastrointestinal or nocturnal frequency side-effects. Only 16 (9%) patients had moderate or severe complications. The multivariate analysis revealed that the risk of posttreatment complications was strongly correlated to pretreatment presence of symptoms from the organs at risk. Posttreatment complications presenting first 3 years after irradiation were rare.

CONCLUSIONS

Radical external beam radiotherapy (70 Gy) can be given with a low risk of severe complications. It appears reasonable to assume that the risk can be further reduced by excluding patients with gastrointestinal and urinary tract disease or symptoms.

Urinary incontinence and sexual impotence after radical prostatectomy

Telephone interviews concerning urinary continence and sexual potency in 152 men who had undergone radical prostatectomy for localized cancer were conducted by an investigator who had not been involved in the patients' treatment. The obtained data were compared with the surgeons' recorded follow-up notes. Continence was defined according to ICS criteria and potency as the capacity for vaginal penetration. At the interviews, 74 men (49%) reported total continence and 39 others (26%) were acceptably dry; 32 required more than two small protective pads per day, five had received an artificial sphincter implant and two had supravesical urinary diversion (Kock pouch), making 39 (25%) classified as incontinent. The surgeons' records, however, showed an 89% continence rate and 87% of these men had regained continence within 24 weeks of the operation. Of 134 preoperatively potent men, only 21 (14%) remained potent in the first postoperative year. That earlier reported excellent results regarding continence and potency were not reproduced in our study, possible was partly due to our inclusion of more advanced tumours in somewhat older patients, but the fact that the interviewer was independent of the surgeon significantly influenced the results.

Deoxythymidine kinase in the staging of prostatic adenocarcinoma

The role of prostate-specific antigen in the management of prostatic adenocarcinoma is still not fully ascertained. Its place in the monitoring of patients who have undergone radical treatment is without question but its role in the primary assessment of a lesion is a point of continuous discussion. This study reports the analysis of prostate-specific antigen (PSA) in 92 patients with different stages of prostatic adenocarcinoma prior to treatment; in the case of the localized lesions, this was based to a great extent on the findings at lymphadenectomy. Apart from PSA analysis, deoxythymidine kinase (dTK) analyses were also performed in an attempt to discover whether the latter could provide additional information about the tumor load in the different patient categories, viz. those with lymph node involvement (group 1), those with lymph node involvement but without distant metastases (group 2), and those with disseminated disease (group 3). The median PSA and dTK values in groups 1-3 were 6.5 micrograms/L and 2.7 U/microliter, 16 micrograms/L and 2.6 U/microL, and 90 micrograms/L and 7.8 U/microL, respectively. If the two analyses were used concomitantly, they could differentiate true localized disease from metastatic in approximately 92% of cases. The combination should prove of value in the primary assessment of a patient with a newly diagnosed prostatic adenocarcinoma.

Adverse effects after radical external beam radiotherapy of localized prostatic adenocarcinoma using two-dimensional dose-planning and a limited field technique

Adverse effects were assessed after definitive limited field, 2-dimensional CT-planned radiation treatment of localized prostatic adenocarcinoma. In 66 surviving patients, out of a total of 176 treated patients, personal interviews were performed and self-administered questionnaires distributed. The average follow-up was 6.6 years. Adverse effects with regard to bowel function and micturition were investigated, and graded 0-4 with increasing severity and impact on performance status, essentially according to the RTOG toxicity scoring system. Sexual functions were registered on visual analogue scales. The majority of adverse effects were considered minor (grade 1) and did not require any treatment. Late adverse effects on bowel and bladder or urethra that required treatment (grade 2-4) were reported in up to 8% (n = 5) of cases respectively. Late bowel side-effects that interfered with life style (grade 3-4) occurred in up to 3% (n = 2) of patients; the majority were rectal complications. Corresponding urinary side-effects were registered in up to 6% (n = 4) of the patients. Major surgical interventions were not required. Sexual functions were substantially affected in 60% of cases not administered endocrine treatment. Multivariate analyses could not identify patient or treatment risk factors related to complications.

Long-term survival and mortality in prostate cancer treated with noncurative intent

PURPOSE

We investigate the long-term outcome of patients with prostate cancer treated with noncurative intent.

MATERIALS AND METHODS

All 514 prostate cancer patients who died between 1988 and 1991 and who underwent either deferred or immediate hormonal treatment were followed from death until diagnosis.

RESULTS

In all patients with stage M0 disease at diagnosis the ultimate cancer mortality rate was 50%. Among the 65 patients who survived at least 10 years the mortality rate due to prostate cancer was 63%.

CONCLUSIONS

Mortality in patients with stage M0 prostate cancer was surprisingly high when followup exceeded 10 years.

Five year follow-up after radical prostatectomy for localized prostate cancer--a study of the impact of different tumor variables on progression

Fifty-one patients with clinically localized prostate cancer stages A and B, who underwent radical prostatectomy have been followed for a minimum of 5 years. The impact of age, stage, capsular penetration, total tumor volume, Gleason score, seminal vesicle invasion and lymph node metastases on progression has been evaluated. Progression free survival was calculated according to the Kaplan-Meier method. Uni- and multivariate analyses were performed according to the Cox proportional hazards model. During the observation period 16 patients (31%) experienced progression. Tumor volume, grade and seminal vesicle invasion emerged as statistically significant predictors of tumor progression in the survival analyses while age at surgery, preoperative stage and different levels of capsular penetration were not statistically significant. The findings in the Cox models were in accordance with those at actuarial survival analyses though tumor volume was the only variable proven to have an independent statistically significant influence on progression.

Self-assessment questionnaire for evaluating urinary and intestinal late side effects after pelvic radiotherapy in patients with prostate cancer compared with an age-matched control population

BACKGROUND

Pelvic irradiation to patients with prostate cancer is accompanied by urinary and intestinal reactions. In men older than 60 years, treatment-induced problems should be evaluated in relation to problems in an age-matched nonirradiated population.

METHODS

In the present study, problems in the urinary tract and intestine were evaluated with a self-assessment questionnaire using the linear-analogue scale. The questionnaire was mailed out to 200 patients and to an age-matched population 24-56 months after irradiation.

RESULTS

Twenty-five percent of the control group and 50% of the patient group reported some kind of problem in the urinary tract. The most common urinary problems in the control group and in the patient group, respectively, were urgency (19 and 42%), starting problems (22 and 33%), and leakage (11 and 32%). In the control and patient groups, 14 and 59%, respectively, reported some kind of gastrointestinal problems. The most common intestinal problems in the control and patient groups were respectively, mucus (4 and 38%), cramp (5 and 14%), leakage (2 and 27%), and blood (2 and 36%). Ninety percent of the patients' problems were minor.

CONCLUSION

Pelvic irradiation induced a relatively large number of minor problems, evaluated with a self-assessment questionnaire and compared with an age-matched population of men, of approximately similar magnitude as with a physician's systematic evaluation. The most important urinary factors were urgency and leakage. The most important intestinal factors were blood, mucus, and leakage. The results support the ongoing efforts to use 3-D computed tomography-based conformal therapy to decrease irradiation dose to the rectum and bladder.