Days Of Radical Prostatectomy Research Articles

Long-term follow-up with a clinical decision support system based on laboratory reports to manage patients with biochemical recurrence after radical prostatectomy

IntroductionCurrently, prostate cancer (PCa) is the second most common cause of cancer death, and radical prostatectomy (RP) remains the primary treatment for localized PCa. Although there is no consensus on an optimal strategy, the determination of total serum prostate-specific antigen (tPSA) is the cornerstone for the detection of postoperative biochemical recurrence (BCR). The aim of this study was to evaluate the prognostic utility of serial tPSA levels together with other clinicopathological factors and to assess the impact of a commentary algorithm implemented in our laboratory information system. MethodsA descriptive and retrospective study of patients with clinically localized PCa who underwent RP. BCR-free survival was calculated over time (Kaplan-Meier analysis), and the ability of different clinicopathological factors to predict BCR was studied (univariate and multivariate analyses) with Cox models. ResultsA total of 203 patients underwent RP, of whom 51 presented with BCR during follow-up. In the multivariate model, doubling of tPSA, the Gleason score, tumour stage and tPSA nadir were detected as independent predictors of BCR. ConclusionA patient with undetectable tPSA after 1959 days of RP is unlikely to develop BCR, regardless of preoperative or pathologic risk factors. Furthermore, doubling of tPSA in the first 2 years of follow-up was the main prognostic factor for BCR in patients undergoing RP. Other prognostic factors included a tPSA nadir detectable after surgery, a Gleason score ≥ 7 and a tumour stage T ≥ 2c.

MP77-14 PATIENT AND FACILITY FACTORS ASSOCIATED WITH 90-DAY MORTALITY AFTER RADICAL PROSTATECTOMY FOR PROSTATE CANCER

You have accessJournal of UrologyCME1 Apr 2023MP77-14 PATIENT AND FACILITY FACTORS ASSOCIATED WITH 90-DAY MORTALITY AFTER RADICAL PROSTATECTOMY FOR PROSTATE CANCER Folawiyo Laditi, James Nie, Victoria Marks, and Michael Leapman Folawiyo LaditiFolawiyo Laditi More articles by this author , James NieJames Nie More articles by this author , Victoria MarksVictoria Marks More articles by this author , and Michael LeapmanMichael Leapman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003351.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although perioperative mortality after radical prostatectomy for prostate cancer is rare, less is known about the extent to which risks posed by patient factors can be modified by care at higher-volume centers. We aimed to assess the incidence and risk factors of mortality within 90 days of radical prostatectomy. METHODS: We conducted a retrospective analysis of The National Cancer Database, to identify patients undergoing radical prostatectomy from 2004-2017. We characterized the incidence of death within 90 days of surgery and described clinical, demographic and facility-level factors associated with the outcome, including surgical volume. Mixed effect logistic regression models incorporating a facility random intercept were constructed to examine factors associated with 90-day mortality. RESULTS: We identified 313,071 patients who underwent prostatectomy in the study period. The incidence of 90-day mortality was 0.22%. Mixed effect logistic regression revealed that 90-day mortality was associated with older age (1.47 OR per 5 years, 95% CI 1.39-1.56), higher PSA (>20 mg/mL, OR 2.25, 95% CI 1.88-2.68), receipt of lymph node dissection (OR 1.26, 95% CI 1.05-1.51), high-school degree attainment in patient’s residential zip code by quartile (>93.7% of zip code with degrees, OR 0.70, 95% CI 0.55-0.90, Black race (OR 1.91, 95 %CI 1.57-2.32), higher Charlson-Deyo Morbidity Index (OR 1.50 95% CI 1.25-1.81 for score of 1; OR 2.72 95% CI 2.00-3.72 score of 2; OR 3.72 95% CI 2.36-5.88 for score of 3+) and surgical volume above median (OR 0.80, 95% CI 0.66-0.97). CONCLUSIONS: 90-day mortality after radical prostatectomy is rare, but associated with hospital surgical volume and patient- level factors including higher risk disease, higher comorbidity and race. Findings of racial disparity in perioperative mortality suggest a timely need to explore the contributions of patient selection and quality of care. Source of Funding: This publication was made possible by the Yale School of Medicine Fellowship for Medical Student Research © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1107 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Folawiyo Laditi More articles by this author James Nie More articles by this author Victoria Marks More articles by this author Michael Leapman More articles by this author Expand All Advertisement PDF downloadLoading ...

Survival after radical prostatectomy for clinically localised prostate cancer: a population‐based study

To describe survival and cause of death in a nationwide cohort of Danish patients with prostate cancer undergoing radical prostatectomy (RP). To describe risk factors associated with prostate cancer mortality. Observational study of 6489 men with localised prostate cancer treated with RP at six different hospitals in Denmark between 1995 and 2011. Survival was described using Kaplan-Meier estimates. Causes of death were obtained from the national registry and cross-checked with patient files. Cumulative incidence of death, any cause and prostate cancer-specific, was described using Nelson-Aalen estimates. Risk for prostate cancer death was analysed in a Cox multivariate regression model using the covariates: age, cT-category, PSA level and biopsy Gleason score. The median follow-up was 4 years. During follow-up, 328 patients died, 109 (33.2%) from prostate cancer and 219 (66.8%) from other causes. Six patients (0.09%) died ≤30 days of RP. In multivariate analysis, cT-category was a predictor of prostate cancer death (P < 0.001). Compared with T1 disease, both cT2c (hazard ratio [HR] 2.2) and cT3 (HR 7.2) significantly increased the risk of prostate cancer death. For every doubling of PSA level the risk of prostate cancer death was increased by 34.8% (P < 0.001). Biopsy Gleason score 4 + 3 and ≥8 were associated with an increased risk of prostate cancer death compared with biopsy Gleason score ≤ 6 of 2.3 and 2.7 (P = 0.003), respectively. The cumulative hazard of all-cause and prostate cancer-specific mortality after 10 years was 15.4% (95% confide3nce interval [CI] 13.2-17.7) and 6.6% (95% CI 4.9-8.2) respectively. We present the first survival analysis of a complete, nationwide cohort of men undergoing RP for localised prostate cancer. The main limitation of the study was the relatively short follow-up. Interestingly, our national results are comparable to high-volume, single institution, single surgeon series.

1629 PREOPERATIVE TOTAL TESTOSTERONE LEVELS DO NOT PREDICT PATHOLOGIC STAGE IN CLINICALLY LOCALIZED PROSTATE CANCER

You have accessJournal of UrologyProstate Cancer: Localized1 Apr 20111629 PREOPERATIVE TOTAL TESTOSTERONE LEVELS DO NOT PREDICT PATHOLOGIC STAGE IN CLINICALLY LOCALIZED PROSTATE CANCER Jonathan Silberstein, Doron Stember, Andrew Vickers, Nicholas Power, Peter Scardino, James Eastham, and John Mulhall Jonathan SilbersteinJonathan Silberstein New York City, NY More articles by this author , Doron StemberDoron Stember New York City, NY More articles by this author , Andrew VickersAndrew Vickers New York City, NY More articles by this author , Nicholas PowerNicholas Power New York City, NY More articles by this author , Peter ScardinoPeter Scardino New York City, NY More articles by this author , James EasthamJames Eastham New York City, NY More articles by this author , and John MulhallJohn Mulhall New York City, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1738AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Substantial controversy exists in the literature regarding the association between testosterone levels and pathologic outcome in patients with prostate cancer. We explored the relationship between morning preoperative total testosterone and pathologic stage in patients with clinically localized prostate cancer treated with radical prostatectomy (RP). METHODS We retrospectively reviewed the records of consecutive patients with localized prostate cancer treated with RP from 2002–2010. Patients with preoperative history of androgen deprivation therapy or radiation therapy were excluded from analysis. A total of 445 patients with documented AM (before 12 noon) testosterone drawn within the 3 months prior to RP were available for analysis. Subgroup analysis was performed on 207 patients with AM testosterone levels within 30 days of RP. Univariate and multivariate logistic regression analysis were done to examine whether pre-RP testosterone was associated with pathologic stage. Multivariate analyses controlled for clinical stage, grade and PSA. RESULTS For the entire cohort median age was 59.6 years (Interquartile range (IQR) 54.1, 64.8), PSA was 5.25 ng/ml (IQR 3.65, 7.33), testosterone was 395 ng/dl (IQR 299, 467). In 275 (62%) patients disease was organ confined, 174 (34%) had extracapsular extension, 27 (6%) had seminal vesical invasion and 42 (10%) had positive lymph nodes. There were no statistically significant associations between testosterone within 90 days and pathologic outcomes on either univariate or multivariate analysis using testosterone as a continuous variable. Repeating the analysis for men with testosterone taken within 30 days of surgery failed to change the conclusion of no effect. To account for a potential non-linear relationship between morning testosterone and pathologic outcomes we conducted a post hoc analysis using restricted cubic splines. This also failed to demonstrate any plausible association. CONCLUSIONS We found no evidence to suggest that preoperative morning testosterone levels are associated with pathologic outcomes in patients undergoing RP. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e653 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan Silberstein New York City, NY More articles by this author Doron Stember New York City, NY More articles by this author Andrew Vickers New York City, NY More articles by this author Nicholas Power New York City, NY More articles by this author Peter Scardino New York City, NY More articles by this author James Eastham New York City, NY More articles by this author John Mulhall New York City, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Nationwide population-based study on 30-day mortality after radical prostatectomy in Sweden

The incidence of prostate cancer in Sweden is increasing rapidly, as is treatment with curative intent. Radical prostatectomy (RP) is currently commonly performed, either within or outside large high-volume centres. The aim of this study was to assess the 30-day mortality rate after RP in Sweden. In this nationwide population-based study, all men diagnosed with localized prostate cancer (< or =70 years, clinical stadium T1-2, prostate-specific antigen < 20 ng/ml) who underwent RP in Sweden between 1997 and 2002 were identified through the National Prostate Cancer Register (NPCR). Mortality within 30 days of RP was analysed through linkage between the follow-up study of the NPCR and the Regional Population Registers. The cause of death in the death certificates were compared with data from the hospitals concerned. To validate the results, a record linkage between the Inpatient Register and the National Population Register was also performed. The number of RPs performed increased over time. Among 3700 RPs performed, four deaths occurred during the first 30 days, yielding a 0.11% 30-day mortality rate. These deaths occurred at three different types of hospital and were all probably related to the RP. This study provides further evidence that RP is a procedure with very low perioperative mortality even when performed outside high-volume centres.

Role of Androgen Deprivation Therapy for Node-Positive Prostate Cancer

To determine the impact of adjuvant androgen deprivation therapy (ADT) for patients who have node-positive prostate cancer in the prostate-specific antigen (PSA) era. We used linked Surveillance, Epidemiology and End Results-Medicare data to construct a cohort of men who underwent radical prostatectomy (RP) between 1991 and 1999 and who had positive regional lymph nodes. We classified men as receiving adjuvant ADT if they received ADT within 120 days of RP, and we compared them to the men who had not received adjuvant ADT. We used propensity scores to balance potential confounders of receiving adjuvant ADT (ie, tumor characteristics, extent of nodal disease, demographics, receipt of radiation therapy) and Cox proportional hazard methods to measure the impact of adjuvant ADT on overall survival (OS), stratified by propensity score quintile. We conducted a sensitivity analysis that used 90, 150, 180, and 365 days as the definition for adjuvant ADT. A total of 731 men were identified, 209 of whom received ADT within 120 days of RP. There was no statistically significant difference in OS between the adjuvant ADT and non-ADT group (HR, 0.97; 95% CI, 0.71 to 1.27). There was no statistically significant survival difference with 90, 150, 180, and 365 days as the adjuvant ADT definition. Deferring immediate ADT in men with positive lymph nodes after RP may not significantly compromise survival. Because observational studies should be considered hypothesis-generating studies, these results should be validated in a prospective fashion in a similar patient population.

Androgen deprivation therapy (ADT) for node postive prostate cancer

5061 Background: The role of ADT for men with node positive prostate cancer following radical prostatectomy (RP) is unclear. One randomized trial has shown a survival advantage for men treated with immediate adjuvant (adj) ADT compared treatment at onset of clinical metastases. However, benefit of immediate therapy is less clear in the PSA era when ADT can initiated at the time of biochemical relapse. Methods: We used linked Surveillance, Epidemiology and End Results-Medicare Data to identify a cohort of men who underwent RP between 1991–1999 and were found to have positive regional lymph nodes. We searched Medicare claims to identify men with claims for ADT (hormonal therapy or orchiectomy) within 3 years of diagnosis. We excluded men who received ADT prior to RP. We classified men as receiving adj ADT if they received treatment within 120 days of RP and compared them to men who had not received adj ADT. We used propensity scores to balance potential confounders of receiving adj ADT (age, tumor characteristics, extent of nodal disease, demographics). We used Cox proportional hazard methods to estimate the impact of adj ADT on overall survival (OS) adjusting for propensity score. We conducted a sensitivity analysis using 90, 150, 180 and 365 days as the time limit for adj ADT. Results: 719 men were identified, of whom 190 received adjuvant ADT within 120 days of RP. There was no statistically significant difference in overall survival between the men who did or did not receive adj ADT (HR 0.96 95% CI 0.70–1.32) The results were similar for men who received ADT within 90 and 150 days. However, when the definition of adj ADT was moved to 180 days (HR 1.08 (0.80–1.47)) and 365 days (HR 1.24 (0.92–1.65)) the men receiving adj ADT had a slightly higher risk of death, suggesting some in the adj ADT groups using these later definitions may have received therapy as salvage therapy for progressive disease. Conclusions: This observational study suggests that in the PSA era when men can be started on ADT at the time of biochemical recurrence, overall survival may not be significantly compromised by deferring immediate ADT in men with positive lymph nodes following RP. Further clinical research is needed to better understand which patients are likely to benefit from immediate ADT, and which men can be spared the long term toxicities. [Table: see text]

Preoperative evaluation of the ‘hostile pelvis’ in radical prostatectomy with computed tomographic pelvimetry

To determine whether preoperative pelvimetry based on computed tomography (CT) can be used to predict technical difficulties during open radical prostatectomy (RP). An open RP database accrued prospectively between January 1997 and June 2005 was used to identify 450 patients with preoperative pelvic imaging. Of these, 165 had adequate imaging of the pelvis with CT to allow pelvimetry using software provided with the medical imaging records. Several pelvic measurements were recorded in conjunction with body mass index and transrectal ultrasonographic estimates of prostatic volume. Outcome measures used to reflect technical surgical difficulties included operative duration, blood transfusion requirements within 30 days of RP, the pathological positive surgical margin and prostatic capsular breech rate. Logistic and linear regression analyses were used to determine the relationship between variables before and after RP. The selected pelvimetric measurements failed to predict either operative duration or the peri-operative blood transfusion requirement. Prostatic volume was predictive of operative duration; for every increase of 20 mL in prostate volume the duration increased by 8.4 min. Although pelvimetric measures failed to predict positive surgical margins at pathology, the transverse diameter predicted the likelihood of a positive margin due to capsular breech. With every 8.6 mm (1 sd) decrease in transverse diameter, the odds of a capsular breech resulting in positive surgical margins increased 5.3 times (95% confidence interval 2.1-20.0, P = 0.002). Although the "hostile pelvis" influences the likelihood of prostatic capsular breech resulting in positive surgical margins, CT pelvimetric screening of patients before RP is unlikely to be cost-effective. Routine pelvic CT in the evaluation of patients before RP is not supported.

Rethinking 30-day mortality risk after radical prostatectomy

Objectives Although radical prostatectomy (RP) is associated with greater 30-day mortality in older men, the magnitude of the excess risk in older age groups compared with younger ones has not been well characterized. Methods Using data from the Ontario Cancer Registry, we identified 11,010 men who underwent RP from 1990 to 1999 in Ontario, Canada and compared the 30-day mortality risk immediately after RP with the 1-month mortality risk in the same population of men 7 to 12 months after RP and that of an age-matched general population of men. Results Overall, 53 men (0.48%) died within 30 days of surgery. The absolute excess 30-day mortality risk associated with RP was 0.18%, 0.51%, and 0.59% for men aged 50 to 59, 60 to 69, and 70 to 79 years, respectively, and was similar for men aged 60 to 69 and 70 to 79 years ( P >0.05). The relative mortality risk within 30 days of RP was approximately nine times the baseline risk (95% confidence interval 3 to 38) and was similar for men in all three age groups ( P >0.05). Conclusions The results of our study indicate that men aged 70 to 79 years do not have a greater absolute excess or relative risk of 30-day mortality after RP compared with men aged 60 to 69 years.

30-Day Mortality and Major Complications after Radical Prostatectomy: Influence of Age and Comorbidity

Radical prostatectomy is associated with excellent long-term disease control for localized prostate cancer. Prior studies have suggested an increased risk of short-term complications among older men who underwent radical prostatectomy, but these studies did not adjust for comorbidity. We examined mortality and complications occurring within 30 days following radical prostatectomy among all 11,010 men who underwent this surgery in Ontario, Canada, between 1990 and 1999 using multivariable logistic regression modeling. We adjusted for comorbidity using two common comorbidity indices. Statistical tests were two-sided. Overall, 53 men (0.5%) died, and 2195 [corrected] (19.9%[corrected]) had one or more complications within 30 days of radical prostatectomy. In models adjusted for comorbidity and year of surgery, age was associated with an increased risk of 30-day mortality (odds ratio = 2.04 per decade of age, 95% confidence interval [CI] = 1.23 to 3.39). However, the absolute 30-day mortality risk was low, even in older men, at 0.66% (95% CI = 0.2 to 1.1%) for men aged 70-79 years. In adjusted models, age was associated with an increased risk of cardiac (Ptrend < .001), respiratory (Ptrend = .01), and miscellaneous medical (Ptrend = .058) complications. Similarly, increasing comorbidity was associated with a higher risk of all categories of complications. Increasing comorbidity is a stronger predictor than age of almost all categories of early complications after radical prostatectomy. The risk of postoperative mortality after radical prostatectomy is relatively low for otherwise healthy older men up to age 79.

Examining the location and the cause of death within 30 days of radical prostatectomy

Examining the location and the cause of death within 30 days of radical prostatectomy

Examining the location and cause of death within 30 days of radical prostatectomy

To better characterize the cause and location of death after radical prostatectomy (RP), as early mortality is relatively uncommon after RP, with little known about the cause of death among men who die within 30 days of RP, and the trend toward earlier discharge after surgery means that a greater proportion of early mortality after RP may occur out of hospital. Using the Ontario Cancer Registry, we identified 11,010 men (mean age 68 years) who had a RP in the province of Ontario between 1990 and 1999. We identified the occurrence and location of all deaths within 30 days of RP. The cause of death was obtained from death certificate information. Logistic regression was used to examine factors (age, comorbidity, year of surgery) associated with the location of death. Of the 11,010 men, 53 died within 30 days of RP (0.5%); of these 53 men, 28 (53%) died in hospital. Neither age, comorbidity nor year of surgery were significantly associated with location of death (P > 0.05). Major causes of death included cardiovascular disease (38%) and pulmonary embolism (13%). More than half of the patients who died out of hospital had an unknown cause of death. Almost half of all deaths within 30 days of RP occur out of hospital; the two most common causes of death are potentially preventable. More detailed cause-of-death information may help to identify opportunities for prevention.

DEFINING PROSTATE SPECIFIC ANTIGEN PROGRESSION AFTER RADICAL PROSTATECTOMY: WHAT IS THE MOST APPROPRIATE CUT POINT?

The most appropriate definition of biochemical progression after radical prostatectomy and radiation therapy is uncertain. We analyzed the effect of using various prostate specific antigen (PSA) end point definitions for defining biochemical progression after radical prostatectomy and attempted to determine the best PSA cut point to use. Aspects of the American Society for Therapeutic Radiology and Oncology (ASTRO) definition of biochemical failure after radiation therapy are also analyzed in our radical prostatectomy cases. A total of 2,782 men with clinically localized prostate cancer (cT1-T2) who had undergone radical prostatectomy between 1987 and 1993 were reviewed. All patients had regular PSA determinations from surgery through followup. Analysis was limited to patients who did not receive adjuvant treatment within 90 days of radical prostatectomy. Biochemical, PSA progression-free percent after radical prostatectomy was determined by the Kaplan-Meier method using several PSA cut points, including 0.2, 0.3, 0.4 and 0.5 ng./ml. or greater, as well as 0.4 ng./ml. or greater and increasing. Progression-free percent was also assessed using the ASTRO definition, which is 3 increases in PSA. To determine which PSA level was most appropriate to define progression after radical prostatectomy, the percentage of patients with a continued PSA increase after reaching each cut point was determined. The relationship between the maximum PSA within 3 years of surgery and subsequent development of clinical disease was also assessed. Progression-free percent was dependent on the PSA cut point used. Biochemical progression-free percentages for cut points 0.2, 0.3, 0.4 and 0.5 ng./ml. or greater were 62%, 72%, 76% and 78% at 5 years, and 43%, 54%, 59% and 61% at 10 years, respectively. A subsequent increase in PSA was noted in 49%, 62% and 72% of patients who had PSA 0.2, 0.3 and 0.4 ng./ml., respectively. Subsequent clinical progression (local or systemic) was directly related to the maximum PSA attained within 3 years of radical prostatectomy (p=0.0001). Progression-free percent for definitions requiring multiple increases in PSA were dependent on when the event was said to occur. Backdating of events at or before the first PSA (ASTRO definition) resulted in poorer, short-term progression-free percent (78% at 5 years), with little apparent likelihood of long-term failure (78% at 10 years). Coding the event at the last PSA increase when all event criteria had been met resulted in more realistic progression-free percent estimates (85% at 5 and 59% at 10 years). Biochemical, PSA progression rates vary markedly depending on the method used to define PSA failure. Methods that require multiple increasing PSA values, for example the ASTRO definition, give misleading results, especially if the event time is backdated. Standards for defining PSA progression would allow more consistent and comparable progression estimates after radical prostatectomy. PSA 0.4 ng./ml. or greater may be the most appropriate cut point to use since a significant number of patients with lower PSA do not have a continued increase in it.

LONG-TERM HAZARD OF PROGRESSION AFTER RADICAL PROSTATECTOMY FOR CLINICALLY LOCALIZED PROSTATE CANCER: CONTINUED RISK OF BIOCHEMICAL FAILURE AFTER 5 YEARS

Cure from malignancy is commonly defined as a disease-free state lasting 5 years after treatment. We analyzed clinical and biochemical progression rates after radical prostatectomy for men with clinically localized prostate cancer with particular attention to recurrence beyond 5 years. Annual hazard rates of progression were calculated to determine the probability of recurrence at specific intervals following surgery. The records of 2,782 men with clinically localized prostate cancer (cT1-T2) undergoing radical prostatectomy between 1987 and 1993 were reviewed. All patients were treated in the prostate specific antigen (PSA) era so that serial followup PSA values were available from the time of surgery. Analysis was limited to patients who did not receive adjuvant treatment within 90 days of radical prostatectomy. Disease progression was defined as documented local recurrence, systemic progression and/or PSA 0.4 ng./ml. or greater. Lymph node positive cases were eliminated from analysis since almost all received adjuvant hormonal therapy. Annual hazard rates for progression were calculated using the formula: [No. events / No. patients at risk] x 100. Progression-free survival probabilities were determined using the Kaplan-Meier method. Pathological stage was pT2a-b, N0 (68%), pT3a, N0 (21%) and pT3b, N0 (11%). Biochemical progression-free survival at 5 and 10 years was 76% and 59%, respectively, for the entire study population while those with pathologically organ confined (pT2, N0) cancers had progression-free survival rates of 82% and 68% at 5 and 10 years, respectively. A total of 819 patients (29%) eventually had disease progression, including 160 (6%) with progression after 5 years. Annual hazard rates were highest during the first 2 years after radical prostatectomy for the entire population. Patients with adverse prognostic features (pT3b, PSA 10 ng./ml. or greater, Gleason score 8-10 and nondiploid cancers) had high initial hazard rates that decreased with time to lower levels. Those with pathologically organ confined cancer had low but constant hazard rates throughout followup. Although progression after radical prostatectomy usually occurs early, reflecting the impact of clinical under staging, a significant number of men, including those with organ confined cancers, will continue to have disease progression after 5 years. Patients undergoing radical prostatectomy should be subjected to long-term followup to allow the option of early intervention should progression occur.

Cancer volume of lymph node metastasis predicts progression in prostate cancer.

Clinical outcome is variable in prostate cancer patients with regional lymph node metastasis. We studied 269 patients who had regional lymph node metastasis at the time of radical retropubic prostatectomy and bilateral pelvic lymphadenectomy at the Mayo Clinic between January 1987 and December 1992. Two hundred fifty-three (94%) patients received androgen deprivation therapy within 90 days of radical prostatectomy. Patients ranged in age from 47 to 79 years (median, 67 years). Median follow-up was 6.1 years (range, 0.3-10.5 years). Nodal cancer volume (size) was measured by the grid-counting method. Cox proportional hazards models were used to determine the impact of numerous clinical and pathologic findings on systemic progression-free survival. Systemic progression was defined as the presence of distant metastasis documented by biopsies or radiographic examinations (abdominal computerized tomography, plain radiographs, or bone scan). Five-year progression-free survival was 90%. In predicting systemic progression using Cox multivariate analysis, only nodal cancer volume added significantly to the model containing the primary cancer variables (Gleason score, cancer volume, and DNA ploidy). The relative hazard rate for a doubling in nodal cancer volume was 1.6 (95% confidence interval, 1.3 to 2.0; p < 0.0001). Spearman rank analysis showed a correlation between nodal cancer volume and Gleason score of the primary cancer, the number of positive nodes, the aggregate length of metastases, and the largest nodal cancer diameter (correlation efficient = 0.37, 0.63, 0.96, and 0.95, respectively). Our data indicate that nodal cancer volume was the most significant nodal determinant of progression to distant metastasis in lymph node-positive prostate cancer patients. We recommend that the diameter of the largest metastasis be evaluated in patients with metastases, because this is a more powerful predictor of patient outcome than current methods, which recommend mere counting of the number of positive nodes.

An Assessment of Radical Prostatectomy

Objectives. —To examine temporal trends and geographic variation in radical prostatectomy rates and short-term outcomes. Design. —Population-based study of radical prostatectomy for the years 1984 through 1990. Poisson regression was used to estimate temporal and regional effects. Setting. —The 50 states and the District of Columbia. Participants. —A 20% national sample of male Medicare beneficiaries aged 65 years or older. Main Outcome Measures. —Rate of radical prostatectomy; 30-day mortality; and major cardiopulmonary complications, vascular complications, or surgical repairs within 30 days of radical prostatectomy. Results. —A total of 10598 radical prostatectomies were identified. The adjusted rate of radical prostatectomy in 1990 was 5.75 times that in 1984. The relative increase was similar in all age groups. Substantial geographic variation existed in rates from 1988 through 1990: all states in the New England and Mid-Atlantic regions had rates equal to or below 60 per 100 000 male Medicare beneficiaries, while all states in the Pacific and Mountain regions had rates equal to or above 130 per 100 000. The mortality and morbidity after radical prostatectomy are not trivial for older men (aged 75 years and older)—almost 2% died and nearly 8% suffered major cardiopulmonary complications within 30 days of the operation. Conclusion. —The sharp increase and wide geographic variation in radical prostatectomy rates make the evaluation of this surgical procedure a pressing issue. The rising rate of radical prostatectomy among men aged 75 years and older merits special attention. ( JAMA . 1993;269:2633-2636)