Patients Undergoing Radical Retropubic Prostatectomy Research Articles

The effects of method of anaesthesia on the safety and effectiveness of Radical Retropubic Prostatectomy.

The aim of this study is to determine if patients undergoing radical retropubic prostatectomy with localized prostate cancer under combined (epidural-spinal) anaesthesia have any benefit over patients undergoing the procedure under general anaesthesia. Patients with clinically localised prostate cancer, scheduled for radical retropubic prostatectomy, were allocated to undergo the operation under either general anaesthesia (GA) or under combined (epidural-spinal) (CESA) anaesthesia. Several parameters were recorded both preoperatively (medical history, biometric data, PSA, biopsy Gleason score) and postoperatively (blood pressure, heart rate, haemoglobin levels, operation time and total hospital stay). In addition, mean arterial pressure, change in heart rate, total blood loss, blood transfusions, SAS score, intravenous fluid administration and operation time were also noted down intraoperatively. Patient pain levels and total satisfaction were evaluated using appropriate questionnaires. At the 12-month follow-up, biochemical recurrence using PSA levels and urinary continence status were evaluated. A total of 60 patients were included (30 in each group). Intraoperatively, mean MAP and heart rate change was higher in the GA group (MAP+7,46, HR+27) and mean SAS was higher in the CESA group (+0.93). The time needed for patients' recovery was faster (-3.5 min) and hospitalization was shorter for patients in the CESA group (-0.6 days). Intraoperative blood loss, time for induction and duration of operation were not significantly different. Mean postoperative drop of haemoglobin was greater in the GA group (+0.56) while blood transfusions, VAS pain scores and amount of intravenous fluids did not differ significantly between the two groups. No complications were reported. Patient satisfaction and urinary continence were comparable between the groups and there were no cases of biochemical recurrence. Radical retropubic prostatectomy can safely be performed under combined (spinal epidural anaesthesia, with possible benefits of lower blood loss, less post-operative complications and earlier discharge. Both procedures have equal oncological and functional outcomes at the 12-month follow-up.

Outcomes of radical prostatectomy in patients with prostate cancer at the Aristide Le Dantec University Hospital

Le but était d´évaluer les résultats carcinologiques de la prostatectomie radicale. Il s´agissait d´une étude rétrospective monocentrique au service d´urologie-andrologie de l´Hôpital Aristide Le Dantec de Dakar du 1er juin 2010 au 31 mai 2016. Nous avons colligé 60 cas de prostatectomie radicale par voie rétropubienne associée à un curage ganglionnaire ilio-obturateur. Après la prostatectomie radicale (PR), le taux d’antigène prostatique spécifique (PSA) était indétectable (<0,1 ng/ml) chez 20 patients (33,3%). Onze malades (18,3%) qui avaient une récidive biochimique, ont une hormonothérapie complémentaire. Une réponse a été obtenue après instauration du traitement avec un taux de PSA total redevenu indétectable après un suivi de 8 mois. La durée moyenne de la survie globale était de 17,5 mois avec une médiane de 9,49. Le taux de survie globale cumulé à 1 an, 3 ans et 4 ans étaient respectivement de 42,4, 13,6 et 6,8%. La durée moyenne de la survie sans récidive était de 17,3 mois avec une médiane de survie sans récidive biochimique qui était de onze (11) mois. La durée moyenne de la survie spécifique était de 8,1 mois avec une médiane de 3 mois. Les marges de résection étaient positives chez sept (7) patients soit un taux de 11,6%. Quatre(4) patients avaient un envahissement ganglionnaire. La prostatectomie radicale indiquée dans quelques cas dans notre pratique, est une méthode thérapeutique efficiente avec de bons résultats carcinologiques.

Nociception level-guided opioid administration in radical retropubic prostatectomy: a randomised controlled trial

BackgroundThis RCT investigated the effect of opioid titration by three different nociception monitoring devices or clinical signs during general anaesthesia. MethodsNinety-six patients undergoing radical retropubic prostatectomy with propofol/remifentanil anaesthesia were randomised into one of four groups to receive remifentanil guided by one of three nociception monitoring devices (surgical pleth index [SPI], pupillary pain index [PPI], or nociception level [NOL]) or by clinical judgement (control). Intraoperative remifentanil requirement was the primary endpoint, whereas recovery parameters and stress hormone levels were secondary endpoints. ResultsThe mean [95% confidence interval {CI}] remifentanil administration rate differed between the groups: control 0.34 (0.32–0.37), SPI 0.46 (0.38–0.55), PPI 0.07 (0.06–0.08), and NOL 0.16 (0.12–0.21) μg kg−1 min−1(P<0.001). Intraoperative cessation of remifentanil administration occurred in different numbers (%) of patients: control 0 (0%), SPI 1 (4.3%), PPI 18 (75.0%), and NOL 11 (47.8%); P=0.002. The area under the curve analyses indicated differences in cumulative cortisol levels (mg L−1 min−1) amongst the groups: control 37.9 (33.3–43.1), SPI 38.6 (33.8–44.2), PPI 72.1 (63.1–82.3), and NOL 54.4 (47.6–62.1) (mean [95% CI]). Pairwise group comparison results were as follows: control vs SPI, P=0.830; control vs PPI, P<0.001; control vs NOL, P=0.001; SPI vs PPI, P<0.001; SPI vs NOL, P=0.002; and PPI vs NOL, P=0.009. ConclusionsThe nociception monitoring devices and clinical signs reflect the extent of nociception differently, leading to dissimilar doses of remifentanil. Very low remifentanil doses were associated with an increase and higher remifentanil doses were accompanied by a decrease in serum cortisol concentrations. Use of nociception monitoring devices for guiding intra-operative opioid dosing needs further validation. Clinical trial registrationNCT03380949.

Guiding Opioid Administration by 3 Different Analgesia Nociception Monitoring Indices During General Anesthesia Alters Intraoperative Sufentanil Consumption and Stress Hormone Release: A Randomized Controlled Pilot Study.

This pilot study investigated the effect of sufentanil titration by 3 different analgesia monitoring devices or clinical signs during general anesthesia. Forty-eight patients undergoing radical retropubic prostatectomy with sevoflurane/sufentanil anesthesia were randomly assigned into 4 groups and received sufentanil guided either by 1 of 3 analgesia monitoring devices (Surgical Pleth Index [SPI], Pupillary Pain Index [PPI], Nociception Level [NoL]) or by clinical judgment (control). The primary end point was intraoperative sufentanil consumption. Adrenocorticotropic hormone (ACTH) and cortisol were measured at 4 time points during the day of surgery. Data were analyzed by Kruskal-Wallis and Mann-Whitney U tests and by mixed model and area under the curve (AUC) analyses for group comparisons and time effects of stress hormones. The total amount of sufentanil administration (μg·kg·minute·10) differed between the groups (median [quartiles]: control = 5.6 [4.4-6.4], SPI = 7.2 [4.8-8.4], PPI = 2.0 [1.8-2.9], NoL = 3.8 [3.3-5.1]; PPI versus SPI, -5.1 [-6.6 to -1.3], P < .001; NoL versus SPI, -3.0 [-5.2 to 0.2], P = .024; control versus SPI, -1.6 [-3.7 to 1.7], P = .128; NoL versus PPI, 1.7 [0.6-3.4], P < .001; control versus PPI, 3.4 [2.0-4.6], P < .001; control versus NoL, 1.6 [-0.2 to 3.3], P = .017) (Hodges-Lehmann estimator [99% confidence interval {CI}], P values). The AUC analysis indicated differences among groups in cumulative ACTH levels (ng·liter·minute, natural logarithm (ln)-transformed data) of NoL versus PPI (-1.079 [-1.950 to -0.208], P = .001) and PPI versus SPI (1.192 [0.317-2.068], P= .001), as well as differences in cortisol levels (µg·liter·minute) for PPI versus SPI (46,710 [21,145-72,274], P < .001), NoL versus SPI (27,645 [3163-52,126], P = .003), and control versus SPI (31,824 [6974-56,675], P = .001) (differences in means [99% CI], P value). Secondary end points (postoperative recovery, pain level, and analgesia medication) showed no differences. The type of analgesia nociception monitoring affected the total amount of sufentanil administered. Lower sufentanil doses in the PPI group were associated with an increased endocrine stress response. Titration by SPI caused no opioid reduction compared to the control but was associated with a reduced endocrine stress response.

Moderate alcohol consumption, intraoperative bleeding and postsurgical pain may increase the risk of postoperative delirium in patients undergoing radical retropubic prostatectomy

Background/Aim. The incidence of postoperative delirium (POD) after non-cardiac surgery is a problem not often recognized by many anesthesiologists. The objective of our study was to detect POD and its possible cause, in patients undergoing radical retropubic prostatectomy (RRP) under general anesthesia. Methods. After Ethical Committee approval, we enrolled 80 patients, ASA (the American Society of Anestesiology) status II, scheduled to undergo RRP un-der general anesthesia, in a prospective study. All patients completed MMSE tests (the Folstein Mini Mental State Ex-am) the evening before, and 48 hours after the surgery. Assessment for the presence and severity of delirium was per-formed using CAM (the Confusion Assessment Method), and an assessment of the degree of agitation and sedation using RASS (the Richmond Agitation and Sedation Scale). Results. The average preoperative MMSE score (28.59 ? 1.04) significantly decreased following the surgery (27.74 ? 1.52) (p &lt; 0.0001). The average postoperative MMSE score trend descended in correlation to intraoperative bleeding (p = 0.036). The patients with higher pain scores had significant decline in MMSE after the surgery (28.75 vs. 26.25; p &lt; 0.001). Five patients were considered positive for delirium, and four of them reported regular alcoholic drinks intake (&gt; 1 drink per day) preoperatively (p &lt; 0.0001). Based on RASS score, 13 patients (16.3%) were agitated or sedated, and they had statistically significantly higher intraoperative bleeding (p &lt; 0.001). Conclusion. Results of this study emphasize the importance of proper preoperative evaluation; especially regarding the alcohol consumption since all the patients that developed POD reported moderate alcohol consumption. Further-more, greater intraoperative bleeding and postoperative pain scores did not influence the occurrence of delirium, but resulted in lower postoperative MMSE scores, which high-lights the importance of adequate intraoperative treatment of patients during surgery and anesthesia in order to reduce the risk of developing POD.

Risk factors of perioperative complications in patients undergoing radical retropubic prostatectomy: A ten-year experience

Radical retropubic prostatectomy (RRP) has been one of the most effective treatments for prostate cancer. This study is designed to identify the related predictive risk factors for complications in patients following RRP. Between 2000 and 2012 in Department of Urology, Fudan University Shanghai Cancer Center, 421 cases undergoing RRP for localized prostate cancer by one surgeon were included in this retrospective analysis. We reviewed various risk factors that were correlated with perioperative complications, including patient characteristics [age, body mass index (BMI), co-morbidities], clinical findings (preoperative PSA level, Gleason score, clinical stage, pathological grade), and surgeon's own clinical practice. Charlson comorbidity index (CCI) was used to explain comorbidities. The total rate of perioperative complications was 23.2% (98/421). There were 45/421 (10.7%), 28/421 (6.6%), 24/421 (5.7%) and 1/421 (0.2%) in grade I, II, III, IV respectively, and 323/421 (76.8%) cases had none of these complications. Statistical analysis of multiple potential risk factors revealed that BMI >30 (P=0.014), Charlson score ≥1 (P<0.001) and surgical experience (P=0.0252) were predictors of perioperative complications. Age, PSA level, Gleason score, TNM stage, operation time, blood loss, and blood transfusion were not correlated with perioperative complications (P>0.05). It was concluded that patients' own factors and surgeons' technical factors are related with an increased risk of development of perioperative complications following radical prostatectomy. Knowing these predictors can both favor risk stratification of patients undergoing RRP and help surgeons make treatment decisions.

Health‐related quality of life in prostate cancer patients' – treatment comparisons

ABSTRACTActive surveillance (AS) as treatment option for prostate cancer (PCa) has been systematically offered from Vestfold Hospital Trust since 2009. This option proposes delay or avoidance of radical treatment and its troublesome side effects especially urinary leakage and erectile dysfunction. The aim is to compare urinary problems, sexual dysfunction and health‐related quality of life (HRQOL) between Norwegian PCa patients undergoing radical retropubic prostatectomy (RRP) and AS. A cross‐sectional study of 330 PCa patients diagnosed between 2010 and 2014 at Vestfold Hospital Trust was performed, including 150 in an AS group and 180 in a RRP group. HRQOL was assessed using the SF‐12 questionnaire. Sexual and urinary function was assessed through excerpts from The Expanded Prostate Cancer Index‐50 Question (EPIC‐50). Continuous data was analysed with t‐tests, while categorical data was analysed with χ2‐tests. In addition, linear regression analysis was performed. No difference in HRQOL was observed between the two groups despite significant differences in urinary leakage and sexual function. The AS group had a significantly lower proportion of men with a Physical Component Score (PCS) ≤ 40. We did not find the same pattern for Mental Component Score (MCS). The difference in PCS was not significant after adjustment for treatment, age, relationship and other independent variables. The findings are important for nurses informing PCa patients eligible for AS. The majority of men adjust with their disease and report good HRQOL, despite urinary leakage and erectile dysfunction after RRP compared with nontreated men on AS.

Impact of Radical Prostatectomy on Urinary Incontinence, Erectile Dysfunction and General Quality of Life

The aims of this study were to evaluate the impact of radical retropubic prostatectomy on patient’s quality of life. Patients undergoing radical retropubic prostatectomy were followed for six months after surgery. We used quality of life questionnaires to study specific urinary symptoms and general health. WHOQOL-Bref (World Health Organization for Quality of Life) questionnaire was used to evaluate general health aspects, ICIQ-SF (International Consultation on Incontinence Questionnaire-Short Form), OABq (Overactive Bladder) and IPSS (International Prostatic Symptom Score) to evaluate incontinence and overactive bladder symptoms and Male Sexual Quotient to assess postoperative sexual dysfunctions. The questionnaires were scheduled before surgery, one, three and six months after surgery. Regarding the OAB-q scores, I-PSS and WHOQOL-Bref (physical, psychological, environmental, general, Question 1 and Question 2), symptoms worsened after one month if compared to preoperative symptoms. After six months, the WHOQOL’s social domain, the ICIQ-SF and QS-M scores remained worse if compared to preoperative evaluation. The incidence of sexual dysfunctions after six months was 0.83. In conclusion, urinary incontinence affects patient’s quality of life with gradual recovery after six months postoperatively. The social domain was the most common aspect affected by urinary incontinence. Our sexual dysfunction incidence was higher than other studies and this fact could be explained by many surgeries having been done by residents.

Novel Use of the Capio Urethral Anastomotic Suturing Device: A 50-Case Assessment

Objective: Robotic laparoscopic assisted prostatectomy (RALP) has become the predominant technique for prostatectomy despite significant expense and no robust evidence supporting better cancer control, erectile function, or continence. Several studies have demonstrated lower bladder neck contracture (BNC) rates with RALP, believed to be related to improved visualization and control of the urethrovesical anastomosis. We evaluated the Capio™ radical prostatectomy (RP) suture capturing device for improving anastomotic precision during urethrovesical anastomosis in open radical prostatectomy. Materials and Methods: We performed a retrospective review on a single-surgeon series of 50 consecutive patients undergoing radical retropubic prostatectomy (RRP) with utilization of the Capio™ RP device at an academic hospital (February 2010 to May 2012). Patient demographics, pathology, and outcomes data including rates of anastomotic leak, BNC, erectile function, and continence were collected. Results: Mean age of patients at the time of procedure was 60.4 ± 6.43 years. Patients were stratifed by D'Amico criteria into low (14.3%), intermediate (67.4%), and high (18.4%) risk groups. Mean follow-up for all patients was 13.1 ± 7.29 months. No patients were diagnosed with BNC within 90 days after surgery. Two patients (4%) were subsequently diagnosed and treated for BNC, one of whom was asymptomatic prior to diagnosis. Conclusion: Utilizing the Capio™ RP device during RRP, we were able to achieve a BNC rate equivalent to rates reported for RALP. Use of the Capio™ RP device appears to be a cost-effective method for improving RRP urethrovesical anastomotic results.

Low central venous pressure versus acute normovolemic hemodilution versus conventional fluid management for reducing blood loss in radical retropubic prostatectomy: a randomized controlled trial

Objective:To compare acute normovolemic hemodilution versus low central venous pressure strategy versus conventional fluid management in reducing intraoperative estimated blood loss, hematocrit drop and need for blood transfusion in patients undergoing radical retropubic prostatectomy under general anesthesia.Research design and methods:Patients undergoing radical retropubic prostatectomy under general anesthesia were randomized to conventional fluid management, acute normovolemic hemodilution or low central venous pressure (≤5 mmHg). Treatment effects on estimated blood loss and hematocrit change were tested in multivariable regression models accounting for surgeon, prostate size, and all two-way interactions.Results:Ninety-two patients completed the study. Estimated blood loss (mean ± SD) was significantly lower with low central venous pressure (706 ± 362 ml) compared to acute normovolemic hemodilution (1103 ± 635 ml) and conventional (1051 ± 714 ml) groups (p = 0.0134). There was no difference between the groups in need for blood transfusion, or hematocrit drop from preoperative values. The multivariate model predicting estimated blood loss showed a significant effect of treatment (p = 0.0028) and prostate size (p = 0.0323), accounting for surgeon (p = 0.0013). In the model predicting hematocrit change, accounting for surgeon difference (p = 0.0037), the treatment effect depended on prostate size (p = 0.0007) with the slope of low central venous pressure differing from the other two groups. Hematocrit was predicted to drop more with increased prostate size in acute normovolemic hemodilution and conventional groups but not with low central venous pressure.Key limitations:Limitations include the inability to blind providers to group assignment, possible variability between providers in estimation of blood loss, and the relatively small sample size that was not powered to detect differences between the groups in need for blood transfusion.Conclusions:Maintaining low central venous pressure reduced estimated blood loss compared to conventional fluid management and acute normovolemic hemodilution in patients undergoing radical retropubic prostatectomy but there was no difference in allogeneic blood transfusion between the groups.

Blood Type, Lymphadenectomy and Blood Transfusion Predict Venous Thromboembolic Events Following Radical Prostatectomy with Pelvic Lymphadenectomy

Venous thromboembolic events are the most common nonoperative complication after radical prostatectomy and they represent the most common cause of death within 30 days of surgery. While effective mechanical and chemoprophylaxis exists, such prophylaxis may also be associated with increased complications. To identify venous thromboembolic event risk factors and, thereby, facilitate targeted prophylaxis we characterized clinicopathological variables associated with these events in patients undergoing radical prostatectomy. We reviewed the records of 18,472 consecutive patients who underwent radical prostatectomy with pelvic lymphadenectomy for prostate cancer at our institution from 1987 to 2010. Patients were followed postoperatively for complications. Venous thromboembolic events within 30 days of surgery were recorded. Logistic regression models were used to analyze clinicopathological variables associated with venous thromboembolic events. We identified symptomatic venous thromboembolic events in 271 patients (1.4%). This diagnosis was not associated with preoperative body mass index, prostate specific antigen, Gleason score or cancer recurrence. However, the diagnosis was significantly associated with nonO blood type (OR 1.98, p = 0.004), an increasing number of lymph nodes removed (OR 1.05, p = 0.035) and blood transfusion (OR 1.30, p = 0.02). Patients with venous thromboembolic events were significantly more likely to die within 30 days of surgery (3.0% vs 0%, p <0.001). Blood type, pelvic lymphadenectomy extent and blood transfusion are significant risk factors for symptomatic venous thromboembolic event before radical prostatectomy plus pelvic lymph node dissection. These data should be used for patient counseling, particularly in regard to obviating lymphadenectomy in patients at low risk and for individualizing prophylaxis for venous thromboembolic event in patients at higher risk.

Risk of Incisional Hernia after Minimally Invasive and Open Radical Prostatectomy

The number of radical prostatectomies has increased. Many urologists have shifted from the open surgical approach to minimally invasive techniques. It is not clear whether the risk of post-prostatectomy incisional hernia varies by surgical approach. In the linked Surveillance, Epidemiology and End Results (SEER)-Medicare data set we identified men 66 years old or older who were treated with minimally invasive or open radical prostatectomy for prostate cancer diagnosed from 2003 to 2007. The main study outcome was incisional hernia repair, as identified in Medicare claims after prostatectomy. We also examined the frequency of umbilical, inguinal and other hernia repairs. We identified 3,199 and 6,795 patients who underwent minimally invasive and open radical prostatectomy, respectively. The frequency of incisional hernia repair was 5.3% at a median 3.1-year followup in the minimally invasive group and 1.9% at a 4.4-year median followup in the open group, corresponding to an incidence rate of 16.1 and 4.5/1,000 person-years, respectively. Compared to the open technique, the minimally invasive procedure was associated with more than a threefold increased risk of incisional hernia repair when controlling for patient and disease characteristics (adjusted HR 3.39, 95% CI 2.63-4.38, p<0.0001). Minimally invasive radical prostatectomy was associated with an attenuated but increased risk of any hernia repair compared with open radical prostatectomy (adjusted HR 1.48, 95% CI 1.29-1.70, p<0.0001). Minimally invasive radical prostatectomy was associated with a significantly increased risk of incisional hernia compared with open radical prostatectomy. This is a potentially remediable complication of prostate cancer surgery that warrants increased vigilance with respect to surgical technique.

Longitudinal observational cohort study about detrusor underactivity as a risk factor for bladder neck contracture after retropubic radical prostatectomy: preliminary results

To evaluate the association between preoperative detrusor underactivity (DU) and symptomatic bladder neck contracture (BNC) in patients undergoing radical retropubic prostatectomy (RRP), in order to identify a possible new risk factor in the etiopathogenic mechanisms of BNC after RRP. A total of 100 prostate cancer patients underwent RRP after preoperative complete urodynamic examination. Detrusor contractility was evaluated by bladder contractility index (BCI), power at maximum flow (WF-Qmax), and maximum velocity of detrusorial contraction (MVDC). Follow-up included uroflowmetry with bladder post-voiding volume evaluation at 3 and 6 months after surgery and repeated urodynamic examination at 12 months. Statistical evaluation was performed using the Student's t test (P < 0.01). The mean patient age was 65.6 ± 5.4 years, and pathological stage ranged from T2a to T2c. A total of 40 patients (40 %) presented normal detrusor contractility, 47 (47 %) mild DU, and 13 (13 %) severe DU. Detrusor overactivity (DO) was observed in 12 patients (12 %), small cystometric capacity in 10 (10 %), low compliance in 16 (16 %), DO plus DU (mild or severe) in 6 (6 %), and DO plus small cystometric capacity together with low compliance in 5 (5 %). Normal urodynamics were observed in 38 patients (38 %). Overall BNC incidence was 12. All patients with BNC presented preoperative DU; none presented DO or low bladder compliance. DU severity and BNC occurrence were significantly correlated (P < 0.01) for all 3 urodynamic parameters (BCI, WF-Qmax, and MVDC). We identify DU as a possible novel risk factor for BNC formation after radical prostatectomy that may contribute to its development.

Influence of Body Mass Index, Surgical Approach and Lymphadenectomy on the Development of Symptomatic Lymphoceles after Radical Prostatectomy

Purpose: Identification of factors influencing lymphocele formation requiring intervention after radical prostatectomy. Methods: 302 patients undergoing radical retropubic prostatectomy (RRP, n = 174) or transperitoneal robot-assisted laparoscopic prostatectomy (RALP, n = 128) by the same surgeon were retrospectively reviewed. Incidence of symptomatic lymphoceles (SLC) was compared with clinical and pathological data (contingency analyses, Wilcoxon-Kruskal-Wallis test). Results: Sixteen patients (5.3%) developed SLC. SLC occurred significantly more frequently after RRP compared to RALP (8.0 vs. 0.8%, p = 0.0008). Patients with SLC had more lymph nodes (LN) removed median (17 vs. 13, p = 0.009) and a significantly lower BMI (median 24.4 vs. 26.4, p = 0.0008). Presence of LN metastases (n = 18 patients, 6.0%) showed no statistical impact on SLC. In a multivariate analysis surgical method, the number of resected LN and the BMI remained independent predictors of SLC formation. Conclusions: The lower incidence of SLC after RALP compared to RRP probably results from peritoneal drainage of lymphatic fluid. The correlation of removed LN and SLC might be explained by increased injury of lymphatic vessels during more extended LN dissection. Why patients with lower BMI are more prone to develop SLC still remains unclear. However, early postoperative mobilization in nonobese patients might be a contributing factor.

Effects of Preoperative Gabapentin on Postoperative Pain after Radical Retropubic Prostatectomy

The impact of preoperative gabapentin on tramadol consumption using patient-controlled analgesia (PCA) and postoperative pain was assessed in patients undergoing radical retropubic prostatectomy (RRP). In this prospective, randomized trial, 51 patients undergoing RRP were randomized into two groups: the gabapentin group received 900 mg gabapentin orally 2 h before surgery; the control group did not receive gabapentin. Postoperative analgesia was provided by tramadol PCA. Pain was assessed using a visual analogue scale for 24 h, postoperatively. Mean cumulative tramadol consumption at 24 h was comparable in the two groups. Pain scores at 45 min, 60 min and 2 h postoperatively, and the number of patients who required rescue analgesia, were significantly lower in the gabapentin group than in the control group. Side-effects were similar in the two groups. Preoperative administration of 900 mg gabapentin did not decrease tramadol consumption, but was associated with lower pain scores in the early postoperative phase and a reduced need for rescue analgesia, compared with controls, in patients undergoing RRP.

Erectile rehabilitation with intracavernous alprostadil after radical prostatectomy: refusal and dropout rates

Study Type--Therapy (outcomes) Level of Evidence 2a. What's known on the subject? and What does the study add? Erectile dysfunction (ED) is a well known implication of radical prostatectomy (RP). Despite the search for technical improvement in the surgical procedure (e.g. nerve-sparing surgery, robot-assisted RP), many patients still suffer from an inability to achieve a satisfactory erection after surgery. In the last 20 years a great effort has been made to re-establish good sexual function in these patients. Many different approaches have been used, such as intracavernous prostaglandin E1 (PGE1), phosphodiesterase-5 inhibitors, vacuum devices and penile prostheses. Although many studies have addressed the main questions about efficacy of different approaches to ED, there is a lack of data about adherence to therapy and the main reasons why patients drop out of these treatment programmes. In the present study, a cohort of men treated with RP underwent a postoperative rehabilitation protocol with PGE1 intracavernous injections. During the follow-up period, we were able to assess a real-life practice pattern of adherence and dropout, evaluating the main causes of therapy discontinuation. This could be of help in the counselling of these patients during the path towards erection recovery. • To assess the rate of compliance in the first 6 months of a rehabilitation protocol that includes intracavernous alprostadil administration in patients undergoing radical retropubic prostatectomy. • To determine the reasons for and timings of dropout from the protocol by the patients and their subsequent outcomes. • All patients undergoing radical prostatectomy (RP) at our institution between 1 January 2007 and 31 December 2009 were considered for a protocol of postoperative intracavernous sexual rehabilitation and were administered entry questionnaires to evaluate their preoperative sexual activity. • Four weeks after surgery, the patients were invited to return for a first visit, where the aim of the protocol and possible risks and benefits were explained. For those who agreed to attend, subsequent visits to include assisted self-administration of increasing doses of intracavernous alprostadil and a period of autonomous homely self-administration were planned. • Patients were followed up at 3-month intervals, where data on functional outcomes, patient satisfaction, and the number of patients who dropped out and their reasons, were recorded by means of appropriate questionnaires. • Statistical analysis was performed using Student's t-test or a chi-squared test, where appropriate. • Of 430 patients, 157 (36.5%) refused to undergo the protocol of rehabilitation and 18.6% of the patients who began the protocol dropped out over the first 6 months. • Reasons for refusal were: patient's lack of sexual interest (51.6%); lack of interest by the partner (30.2%); and presence of transitory incontinence (26.7%). • Reasons for dropout were: disappointment with treatment efficacy (64.7%); injection pain (45%); and difficulties with or fear of performing the injection by themselves or by the partner (35.2%). No patient claimed the cost of the drug to be a cause for dropout. • The protocol we used, involving intracavernous alprostadil injection, proved to be a safe and efficient way of achieving sexual rehabilitation in patients who have undergone RP. Nevertheless, high patient motivation and adherence to the protocol were required. • Factors influencing patients refusal and early-to-medium time dropout were both patient- and partner-related. Appropriate information, counselling and support of the couple before the beginning and at all stages of the rehabilitation play a fundamental role in reducing the dropout rate. • The situation regarding those patients who still need adjuvant therapy after surgery is less clear and further research on this is required.

National Comprehensive Cancer Network Practice Guidelines 2011: Need for More Accurate Recommendations for Pelvic Lymph Node Dissection in Prostate Cancer

The 2011 NCCN (National Comprehensive Cancer Network) guidelines for prostate cancer recommend pelvic lymph node dissection at radical prostatectomy in all individuals with a nomogram predicted lymph node invasion probability of 2% or greater. We examined the ability of these guidelines to correctly predict lymph node invasion in patients treated with extended pelvic lymph node dissection. We examined 3,064 consecutive patients treated with radical prostatectomy and extended pelvic lymph node dissection between 2000 and 2010. We formally validated the NCCN guideline nomogram using discrimination, calibration and decision curve analysis as benchmarks. Moreover the performance characteristics of the 2% nomogram cutoff as well as other cutoff values (range 1% to 10%) were tested. Overall 10.0% of patients had lymph node invasion. The discrimination accuracy of the NCCN guideline nomogram was 79.8%, with a maximum underestimation of the lymph node invasion risk of 41.2%. On decision curve analysis the NCCN nomogram fared better than not performing pelvic lymph node dissection in all patients. However, in the prediction range between 0% and 9% the nomogram did not fare better than performing pelvic lymph node dissection in all patients. The use of the 2% cutoff would allow the avoidance of 49.3% of pelvic lymph node dissections, at the cost of missing 20.3% of patients with lymph node invasion. The NCCN nomogram tends to significantly underestimate the real lymph node invasion rate. Moreover the use of the currently recommended cutoff of 2% to trigger pelvic lymph node dissection might not be appropriate.

Intraoperative use of tranexamic acid to reduce transfusion rate in patients undergoing radical retropubic prostatectomy: double blind, randomised, placebo controlled trial

Objectives To determine the efficacy of intraoperative treatment with low dose tranexamic acid in reducing the rate of perioperative transfusions in patients undergoing radical retropubic prostatectomy.Design Double blind, parallel group,...

Biochemical Recurrence After Radical Prostatectomy: Multiplicative Interaction Between Surgical Margin Status and Pathological Stage

A positive surgical margin after radical prostatectomy is considered an adverse prognostic feature. However, few groups have explored the potential interaction between surgical margin status and other cancer characteristics, specifically pathological stage. We addressed the first degree of interaction between positive surgical margins and other established adverse predictors of biochemical recurrence after radical prostatectomy. We used univariate and multivariate analysis to test the effect of surgical margin status on biochemical recurrence in 4,490 patients treated at a single institution between 1992 and 2008. We systematically tested all first-degree interactions between surgical margin status, and pretreatment prostate specific antigen, pT and pN stage, and radical prostatectomy Gleason sum. If interactions were significant, we quantified the effect on the biochemical recurrence rate. Overall 850 patients (18.9%) had positive surgical margins. In those with negative vs positive surgical margins the 5-year biochemical recurrence-free survival rate was 95% vs 83%, 74% vs 62% and 47% vs 29% for pT2, pT3a and pT3b disease, respectively. In multivariate models only the pT stage-surgical margin status interaction achieved independent predictor status (p = 0.003). Negative vs positive surgical margin multivariate HRs were 1 vs 2.9, 2.3 vs 4.3 and 4.1 vs 5.6 in pT2, pT3a and pT3b cases, respectively. Compared to negative surgical margins, positive surgical margins increase the absolute biochemical recurrence 5-year rate by 12% to 18%. More importantly, positive surgical margins may substantially worsen the prognosis beyond that of the original pathological disease stage.

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Pelvic lymph node dissection (PLND) is performed simultaneously with radical prostatectomy (RP) in patients with prostate cancer to detect possible lymph node (LN) metastasis. However, PLND is typically not performed in patients with low-grade (Gleason score ≤ 6) and low-stage (≤ cT2) prostate cancer, as LN metastasis occurs in < 2% of these patients, 1 Partin A.W. Kattan M.W. Subong E.N. et al. Combination of prostate-specific antigen, clinical state, and Gleason score to predict pathological stage of localized prostate cancer: a multi-institutional study. JAMA. 1997; 277: 1445-1451 Crossref PubMed Google Scholar and lymphocele develops as a postoperative complication in < 10% of patients after PLND. 2 Musch M. Klevecka V. Roggenbuck U. et al. Complications of pelvic lymphadenectomy in 1380 patients undergoing radical retropubic prostatectomy between 1993 and 2006. J Urol. 2008; 179: 923-928 Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar , 3 Pepper R.J. Pati J. Kaisary A.V. The incidence and treatment of lymphoceles after radical retropubic prostatectomy. BJU Int. 2005; 95: 772-775 Crossref PubMed Scopus (52) Google Scholar , 4 Augustin H. Hammerer P. Graefen M. et al. Intraoperative and perioperative morbidity of contemporary radical retropubic prostatectomy in a consecutive series of 1243 patients: Results of a single center between 1999 and 2002. Eur Urol. 2003; 43: 113-118 Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar The symptoms of lymphocele include pelvic pain, leg pain, leg edema, and hydronephrosis. Nonetheless, the therapeutic efficacy of PLND is well known in patients with prostate cancer, and several studies report long-term survival for patients with LN positive prostate cancer treated with RP and PLND. 5 Steinberg G.D. Epstein J.I. Piantadosi S. et al. Management of D1 adenocarcinoma of the prostate; the Johns Hopkins experience 1974-1987. J Urol. 1990; 144: 1425-1432 PubMed Google Scholar , 6 Daneshmand S. Queck M.L. Stein J.P. et al. Prognosis of patients with lymph node positive prostate cancer following radical prostatectomy: long term results. J Urol. 2004; 172: 2252-2255 Abstract Full Text Full Text PDF PubMed Scopus (267) Google Scholar , 7 Pound C.R. Partin A.W. Epstein J.I. et al. Prostate-specific antigen after anatomic radical retropubic prostatectomy: patterns of recurrence and cancer control. Urol Clin North Am. 1997; 24: 395-406 Abstract Full Text Full Text PDF PubMed Scopus (533) Google Scholar However, long-term survival rates are decreased in patients having > 5 positive LNs detected in PLND. 6 Daneshmand S. Queck M.L. Stein J.P. et al. Prognosis of patients with lymph node positive prostate cancer following radical prostatectomy: long term results. J Urol. 2004; 172: 2252-2255 Abstract Full Text Full Text PDF PubMed Scopus (267) Google Scholar Editorial CommentUrologyVol. 76Issue 2PreviewMany analogies have been drawn between prostate cancer and breast cancer.1 A surgical parallel that has not been considered previously, is the management of lymphorrhea after radical prostatectomy. These authors describe the use of octreotide, a potent analog of somatostatin, to reduce significant lymphorrhea after radical retropubic prostatectomy (RRP) and pelvic lymph node dissection (PLND), thereby reducing the morbidity of prolonged lymph drainage. Full-Text PDF