Postoperative Prostate-specific Antigen Level Research Articles

The use of early postoperative prostate-specific antigen to stratify risk in patients with positive surgical margins after radical prostatectomy.

BackgroundIt is well recognized that the presence of positive surgical margins (PSM) after radical prostatectomy (RP) adversely affects cancer specific outcomes and recent evidence from randomized trials supports the use of adjuvant radiotherapy in these cases. However, not all of the patients with PSM develop disease recurrence and the policy of adjuvant radiation could result in considerable over-treatment. We investigated the ability of early postoperative prostate specific antigen (PSA) and PSA decline rates to stratify the risk of disease progression during the first weeks after the surgery thereby allowing adequate time for planning eventual adjuvant therapy.MethodsWe studied 116 consecutive patients with the finding of PSM after RP for localized prostate cancer between 2001 and 2012. No patients were treated with radiation or hormonal therapy. An intensive postoperative PSA monitoring using ultrasensitive assay started first at day 14 after the surgery, then at day 30, 60, 90 and 180, and subsequently in 3 monthly intervals. Biochemical recurrence (BCR) presented the failure of surgical treatment and it was defined as PSA ≥0.2 ng/ml. The ability of PSA decline parameters to predict BCR was assessed using Cox regression model and area under the curve (AUC) calculation.ResultsOverall 55 (47%) patients experienced BCR during median follow-up of 31.4 months (range 6–69). Preoperative PSA, pathologic Gleason sum and pathologic grade failed to reveal any association with observation of BCR. Postoperative PSA levels achieved significant predictive accuracy already on day 30 (AUC 0.74). PSA >0.073 ng/ml at day 30 increased significantly the risk of BCR (HR 4.35, p < 0.001). Predictive accuracy was significantly exceeded on day 60 (AUC 0.84; p < 0.001), while further enhancements on day 90 (AUC 0.84) and 180 (AUC 0.91) were not significant.ConclusionsThe level of ultrasensitive PSA yields valuable information about the prostatectomy outcome already at the first month after the surgery and should aid risk stratification in patients with PSM. Patients not likely to experience subsequent disease progression may be spared the toxicity of immediate adjuvant radiotherapy.

Early return of continence in patients undergoing robot-assisted laparoscopic prostatectomy using modified maximal urethral length preservation technique.

To evaluate the impact of maximal urethral length preservation (MULP) technique in comparison with posterior urethral reconstruction and anterior bladder suspension (PRAS) technique on the continence rates (CR), time to achieve continence among patients with prostate cancer (PCa) undergoing robot-assisted laparoscopic prostatectomy (RALP). We prospectively analyzed the CR, time to achieve continence, pre- and postoperative prostate-specific antigen (PSA) levels, rates of positive margins among three groups of continent men with PCa undergoing RALP from whom consent was obtained. Each group consisted of 30 patients: PRAS was performed in group A, combined MULP and PRAS in group B, and MULP in group C. Continence was measured by patient self-reporting of the number of pads/24 h. No differences were detected in the age, preoperative PSA levels, biochemical recurrence, prostate volume, and positive margins for the three groups. Men in groups B and C had marked improvement in CR 1, 3, and 6 months after catheter removal vs group A (50% and 70% vs 10%, 90% and 96.66% vs 23.3% and 100%, 100% vs 53.3%, respectively, P<0.0001). The average and median times to continence were significantly shorter in group B (5.4 and 4 weeks) and C (3.8 and 3 weeks) vs group A (27.4 and 22.5 weeks), P<0.00001. Using Cox regression analysis, only MULP and MULP+PRAS techniques were significantly correlated with continence outcomes 1, 3, and 6 months after catheter removal. MULP rather than PRAS confers higher postoperative CR and shorter time to achieve continence among patients with PCa who underwent RALP without increasing risk of positive margin.

The 6-item CAPRA-S score predicted cancer recurrence after radical prostatectomy

Source Citation Punnen S, Freedland SJ, Presti JC Jr, et al. Multi-institutional validation of the CAPRA-S score to predict disease recurrence and mortality after radical prostatectomy. Eur Urol. 2013;S0302-2838:00352-7. 23587869

Ductal adenocarcinoma of the prostate: immunohistochemical findings and clinical significance

IntroductionTo investigate the clinical features, diagnosis, treatment, and prognosis of ductal adenocarcinoma of the prostate.MethodsThe clinicopathological and immunohistochemical data of seven patients with ductal adenocarcinoma of the prostate were retrospectively analyzed. All patients underwent physical examination, magnetic resonance imaging (MRI), bone scan, cystoscopy, and computed tomography (CT) scan. The level of prostate-specific antigen (PSA) before and after surgery was assessed. Different prostate cancer markers were used for immunohistochemical staining.ResultsThe mean age of the seven patients diagnosed with prostatic ductal adenocarcinoma in this study was 76.2 years (range 57–88). Five patients presented with intermittent and painless gross hematuria, one patient with progressive dysuria, and one patient with elevated serum PSA on routine health examination. The level of PSA before surgery ranged from 1.3 to 45.0 ng/mL. Immunohistochemical staining results of the prostatic ductal adenocarcinoma confirmed positivity for PSA, prostatic acid phosphatase, androgen receptor, and alpha-methyacyl co-enzyme A (CoA)-reductase markers. Two of the patients underwent bilateral orchiectomy combined with anti-androgen therapy, three underwent transurethral resection of prostate, one received radical prostatectomy, and one received medical castration therapy. The clinical outcomes of all patients were satisfactory, based on follow-up data. The symptoms of hematuria and dysuria were ameliorated well, and the postoperative PSA level decreased below 4.0 ng/mL. Recurrence or metastasis of disease was not detected on MRI and bone scan.ConclusionDuctal adenocarcinoma of the prostate is a rare subtype of prostate carcinoma, the diagnosis of which could be based on pathological and immunohistochemical examination. Earlier management promises better prognosis.

Single‐port transvesical laparoscopic radical prostatectomy for organ‐confined prostate cancer: technique and outcomes

To report a novel technique for performing single-port transvesical laparoscopic radical prostatectomy (STLRP) and to evaluate the oncological and functional outcomes in 16 patients with organ-confined prostate cancer. In total, 16 consecutive patients with clinical stage T1-2aN0M0 were scheduled for STLRP, and their continence and erectile status were investigated preoperatively. The patients' mean age was 62 years, mean prostate volume 42 mL and mean prostate-specific antigen (PSA) 7.5 ng/mL. The STLRP procedures were performed by a single surgeon, and all the operating procedures were conducted transvesically and laparoscopically. Intra-operative and postoperative complications, assessed according to the modified Clavien system, were recorded and peri-operative and functional outcome data were analysed. All patients were followed up for a minimum of 12 months postoperatively through PSA detection, daily pads, the International Index of Erectile Function (IIEF)-6 score and urography. All of the 16 STLRP procedures were successfully completed. The mean (range) operation duration was 105 (75-180) min, and the mean (range) estimated blood loss was 130 (75-500) mL. No patients had positive surgical margins. Postoperative complications occurred in five patients, including three cases of urinary infection and two cases of haematuria (grade II). Catheters were removed after a mean (range) time of 11.2 (9-14) days with cystography. The mean (range) hospital stay was 12.7 (10-15) days. Of the 16 patients, 13 were immediately continent (0 pads/day), and three had mild incontinence (2-3 pads/day) after catheter removal. All patients were observed as continent 3 months postoperatively. In total, 10/16 and 12/16 patients achieved a satisfactory erection at 6 and 12 months follow-up postoperatively, respectively, with an IIEF-6 score ≥ 18. The mean postoperative PSA levels at 3, 6 and 12 months were 0.015 ng/mL, 0.017 ng/mL and 0.016 ng/mL, respectively. No patients were identified with biochemical recurrence in this series. No patients demonstrated vesico-urethral stricture during follow-up for 12-24 months. We conclude that STLRP is technically feasible for patients with low-risk organ-confined prostate cancer and demonstrates promising functional outcomes regarding continence and potency.

Prostatectomy using different lasers for the treatment of benign prostate hyperplasia in aging males

PurposeEndoscopic lasers have become a treatment option for benign prostate hyperplasia (BPH). The study reported here sought to elucidate the benefits and drawbacks of different laser systems in the treatment of patients with BPH.MethodsThe study enrolled 741 patients diagnosed with lower urinary tract symptoms secondary to BPH during the period January 2005 to December 2011. The techniques used in the study were photoselective vaporization of the prostate, thulium laser prostatectomy, and diode laser prostatectomy. Patients were assigned to one of three groups according to the type of laser treatment they received. Outcomes were evaluated using the International Prostate Symptom Score (IPSS), quality of life, maximal urinary flow rate, post-voiding residual urine volume, and prostate-specific antigen (PSA) level.ResultsThe baseline characteristics of patients who received diode laser prostatectomy show a significant elevated risk and high American Society of Anesthesiology score (P=0.001). Operative time and catheter removal time differed significantly between the three groups (P=0.001). No cases were converted to transurethral resection of the prostate intraoperatively due to bleeding (P=0.142). Among the three groups, there were no significant differences in maximal flow rate, lower post-void residual urine, and postoperative PSA level during the entire follow-up period (P<0.05). Further, no significant differences in postoperative IPSS, quality of life, or bladder neck contracture (P=0.23) were observed. However, a significant difference was observed with regard to prolonged use of Foley catheters and prolonged hospital stay among patients in the diode laser group (P=0.001).ConclusionLaser prostatectomies are effective in dealing with lower urinary tract symptoms. Early subjective functional results (maximal flow rate, IPSS, and post-void residual urine) appeared the same as those obtained following laser prostatectomy. Thus, it appears that lasers are safe and effective as long as the patients are carefully selected for treatment.

Persistently elevated prostate-specific antigen at six weeks after radical prostatectomy helps in early identification of patients who are likely to recur

To determine the prognostic factors of biochemical recurrence in patients who failed to achieve an undetectable prostate-specific antigen (PSA) after radical prostatectomy (RP) for prostate cancer. We reviewed data on 240 men who underwent RP as first-line treatment and who had a PSA assay available at 6 weeks after surgery. Persistent detectable PSA was defined as a PSA level ≥ 0.1 ng/ml at 6 weeks after surgery. Overall, 83 men presented persistently elevated PSA after RP and 81 had a biochemical recurrence. Median follow-up was 44 months. In univariate analysis, these factors were associated with biochemical recurrence: preoperative PSA level (P < 0.0001), biopsy and pathologic Gleason score (P < 0.001), capsular involvement (P = 0.0001), positive surgical margins (P < 0.0001), pathological stage ≥ T3 (P = 0.0001), and detectable post-operative PSA ≥ 0.1 ng/ml (P = 0.0001). In a multivariate analysis, only the detectable post-operative PSA level ≥ 0.1 ng/mL (P = 0.001), positive surgical margins (P = 0.002), and pathological stage ≥ T3 (P < 0.001) were significant. The individual, five-year, PSA-free survival rate for men with post-operative PSA <0.1 ng/ml and ≥ 0.1 ng/ml were 59 and 42%, respectively (P < 0.001). A majority of patients who failed to achieve an undetectable PSA after surgery had a subsequent biochemical recurrence in the outcome. A systematic PSA assay 6 weeks after RP could be useful to early identify patients who are likely to recur.

The Effects of Medical Castration on Testes in Patients With Advanced Prostate Cancer

Because of patients' fear of surgery, the psychological symbolism of the male character, and significant encouragement by urologists, the majority of patients with advanced prostate cancer prefer medical castration as a choice of hormonal treatment. We investigated how the preserved testes were affected by medical castration with luteinizing hormone-releasing hormone (LH-RH) agonist and/or antiandrogen therapy. Thirty-four consecutive patients with advanced prostate cancer who underwent a bilateral epididymal-sparing orchiectomy were enrolled in this study. Before surgery, 19 of them had received LH-RH agonists and/or antian-drogens, while the other 15 patients had not. Morphological measurements were made immediately after the operation, and a histological examination was performed by a uropathologist with confirmation by urologists. The axial length, weight, and histopathological findings of the testes and prostate-specific antigen (PSA)/tes-tosterone level were compared between the two groups. Histological changes and characteristics were recorded and analyzed. The median axial length and weight of the testes in the 19 patients with prior medical castration were 2.6 (2.0–3.6) cm and 8.0 (6.0–11.5) g, which significantly differed from those with primary surgical castration [4.0 (2.9–5.0) cm and 12.0 (9.0–17.0) g, both p< 0.001]. Moreover, profound atrophic and fibrosclerotic changes were noted in the seminiferous tubules in the group with prior medical castration. Specific findings, including basement membrane thickening and interstitial cell hyperplasia, were noted in specimens with prior medical castration. However, the postoperative serum PSA and testosterone levels did not significantly differ between the two groups. Medical castration in patients with advanced prostate cancer indeed caused a significant reduction in the volume and profound pathological change in the testes, which may compromise a patient's expectation of his self-image (symbol of sexual virility).

Medications and Surgical Interventions for Benign Prostatic Hyperplasia Are Potential Confounders of Prostate-Specific Antigen

Prostate-specific antigen (PSA) is the most widely used marker for prostate cancer (CaP) screening and monitoring benign prostatic hyperplasia (BPH) progression. However, lack of an established abnormal threshold and the presence of other benign processes confound the interpretation of PSA levels. Many factors besides inflammation, trauma, and instrumentation can influence PSA levels; specifically, BPH and its associated medical and surgical therapies frequently complicate the interpretation of this serum blood test. For example, the commonly used 5 alpha reductase inhibitor (5ARI) medications directly affect PSA levels by decreasing prostate volume. The amount of time and potentially even the 5ARI formulary a patient is administered has been implicated to directly impact the degree of reduction in PSA (a proxy for prostate volume). In addition, each of the currently available surgical procedures for BPH appears to remove varying amounts of prostatic adenoma. This directly confounds CaP screening because each procedure is associated with a relatively specific postoperative nadir PSA level, and PSA kinetics are not well described in the literature. Taken together, it is important for clinicians to comprehend that BPH and its associated medical and surgical interventions should directly influence their interpretation of PSA and PSA velocity when screening for CaP or following BPH progression.

Intrafascial Nerve-Sparing Radical Prostatectomy with a Laparoscopic Robot-Assisted Extraperitoneal Approach: Early Oncological and Functional Results

We investigated whether an intrafascial approach to prostatectomy would provide significantly improved outcomes compared with retropubic and laparoscopic approaches. We performed 50 radical prostatectomies with an intrafascial, nerve-sparing, laparoscopic, robot-assisted extraperitoneal approach. From December 2007 to June 2008, 50 consecutive patients underwent nerve sparing surgery using the intrafascial technique with robotic assistance. All surgeries were performed by the same senior urologist. Patient characteristics and perioperative data were collected prospectively. Oncological outcomes were assessed by pathological examination and postoperative prostate-specific antigen levels. Functional outcomes, including continence, potency, and quality of life, were assessed from patient questionnaires. The mean operative time was 127 minutes (range: 80-205), the mean hospital stay was 4.2 days (range: 2-9), and the mean catheterization time was 7.8 days (range: 4-11). No perioperative complications occurred. One patient required a transfusion at the postoperative stage. The overall positive surgical margin rate was 12%; adjusted by tumor, nodes, and metastasis stage, it was 9.5% in pT2 and 17% in pT3 disease. At the 1-month follow-up, 66% of the patients were continent (no pad), 12% presented a minimal stress urinary incontinence (1 pad), and 22% required >1 pad(s) per day. Further, 60% of patients exhibited potency (erection sufficient for intercourse: 30% without the use of phosphodiesterase 5 inhibitors, 30% required a phosphodiesterase 5 inhibitor) and the remaining 40% required prostaglandin injections. An intrafascial approach with robotic assistance provided satisfactory early functional results with respect to postoperative continence and potency. Long-term oncological results remain to be assessed.

1912 CHANGES IN SERUM PROSTATE SPECIFIC ANTIGEN FOLLOWING HOLMIUM LASER ENUCLEATION OF THE PROSTATE IN PATIENTS WITH BENIGN PROSTATIC HYPERPLASIA

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy and New Technology I1 Apr 20101912 CHANGES IN SERUM PROSTATE SPECIFIC ANTIGEN FOLLOWING HOLMIUM LASER ENUCLEATION OF THE PROSTATE IN PATIENTS WITH BENIGN PROSTATIC HYPERPLASIA Jun Nakashima, Hidaka Kono, Eiji Kikchi, Hirohiko Nagata, Akira Miyajima, Ken Nakagawa, Masaaki Tachibana, and Mototsugu Oya Jun NakashimaJun Nakashima More articles by this author , Hidaka KonoHidaka Kono More articles by this author , Eiji KikchiEiji Kikchi More articles by this author , Hirohiko NagataHirohiko Nagata More articles by this author , Akira MiyajimaAkira Miyajima More articles by this author , Ken NakagawaKen Nakagawa More articles by this author , Masaaki TachibanaMasaaki Tachibana More articles by this author , and Mototsugu OyaMototsugu Oya More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1879AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Holmium laser enucleation of the prostate (HoLEP) has become a useful technique for the treatment of benign prostatic hyperplasia (BPH). However, few studies to date have evaluated the correlation between the change of serum prostate specific antigen (PSA) and effects on volume by HoLEP. The present study was undertaken to evaluate the clinical implication of the PSA changes in the assessment of volume reduction following HoLEP. METHODS The present study includes 68 patients with BPH who have undergone HoLEP for BPH and in whom complete data of PSA were available. Patients who have prostate cancer on histological examination are not included in this study. Serum levels of PSA were measured before and after HoLEP. Prostate volume and transition zone (TZ) volume were measured by transrectal ultrasonography (TRUS) before HoLEP. The changes of serum PSA were correlated with the volume parameters such as the preoperative volume, resected volume, change in the volume and so on. The gravity of the adenoma was estimated to 1g/cc. RESULTS The mean preoperative volume of the prostate and TZ (cc) and the resected volume (g) were 82.8±3.3, 49.4±2.6 and 46.1±3.2, which were significantly correlated with each other. The strong correlation between TZ volume (x) and resected volume (y) (y= -2.2+0.98x, r=0.80) suggests that almost entire TZ volume can be resected by HoLEP. Serum PSA were decreased from 11.5±1.7 to 1.2±0.1 ng/ml with a reduction rate of 84%. The decrease of serum PSA per 1g of resected tissue was 0.27±0.04 ng/ml/g. The reduction rate of serum PSA was significantly correlated with the resected volume (r=0.26) and the resection rate (resected volume/prostate volume, r=0.38; resected volume/TZ volume, r=0.25). The decrease in serum PSA following HoLEP was significantly correlated with the resected volume (r=0.26) and the resection rate (r=0.36). The postoperative serum PSA level following HoLEP was significantly correlated with the residual volume (prostate volume - resected volume) (r=0.43). CONCLUSIONS Almost entire TZ volume can be resected by HoLEP. Serum levels of PSA significantly decreased following HoLEP and the changes in the serum PSA reflected the change in the volume parameters of BPH. The changes of serum PSA may be a useful tool to assess the treatment effects on volume reduction by HoLEP. Tokyo, Japan© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e744 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jun Nakashima More articles by this author Hidaka Kono More articles by this author Eiji Kikchi More articles by this author Hirohiko Nagata More articles by this author Akira Miyajima More articles by this author Ken Nakagawa More articles by this author Masaaki Tachibana More articles by this author Mototsugu Oya More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Need for High Radiation Dose (≥70 Gy) in Early Postoperative Irradiation After Radical Prostatectomy: A Single-Institution Analysis of 334 High-Risk, Node-Negative Patients

To determine the clinical benefit of high-dose early adjuvant radiotherapy (EART) in high-risk prostate cancer (hrCaP) patients submitted to radical retropubic prostatectomy plus pelvic lymphadenectomy. The clinical outcome of 334 hrCaP (pT3-4 and/or positive resection margins) node-negative patients submitted to radical retropubic prostatectomy plus pelvic lymphadenectomy before 2004 was analyzed according to the EART dose delivered to the prostatic bed, <70.2 Gy (lower dose, median 66.6 Gy, n = 153) or >or=70.2 Gy (median 70.2 Gy, n = 181). The two groups were comparable except for a significant difference in terms of median follow-up (10 vs. 7 years, respectively) owing to the gradual increase of EART doses over time. Nevertheless, median time to prostate-specific antigen (PSA) failure was almost identical, 38 and 36 months, respectively. At univariate analysis, both 5-year biochemical relapse-free survival (bRFS) and disease-free survival (DFS) were significantly higher (83% vs. 71% [p = 0.001] and 94% vs. 88% [p = 0.005], respectively) in the HD group. Multivariate analysis confirmed EART dose >or=70 Gy to be independently related to both bRFS (hazard ratio 2.5, p = 0.04) and DFS (hazard ratio 3.6, p = 0.004). Similar results were obtained after the exclusion of patients receiving any androgen deprivation. After grouping the hormone-naïve patients by postoperative PSA level the statistically significant impact of high-dose EART on both 5-year bRFS and DFS was maintained only for those with undetectable values, possibly owing to micrometastatic disease outside the irradiated area in case of detectable postoperative PSA values. This series provides strong support for the use of EART doses >or=70 Gy after radical retropubic prostatectomy in hrCaP patients with undetectable postoperative PSA levels.

Patients with Elevated versus Non-Elevated Prostate Specific Antigen Levels before Suprapubic Prostatectomy: Long-Term Postoperative Follow-Up and Risk for Rising Prostate Specific Antigen and Detection of Prostate Cancer

Objective: Prostate specific antigen (PSA) is one of the most widely applied tumor markers in oncology. The marker is, however, not cancer-specific and may be elevated under other conditions. As prostate cancer may develop after surgery for benign prostate hyperplasia, postoperative follow-up of serum PSA levels is suggested in patients with at least a 10 year life expectancy. We evaluated the preoperative and monitored postoperative serum PSA levels in men who underwent suprapubic prostatectomy (SPP) for benign prostate hyperplasia, and specifically examined the rate of cancer detection in patients who had a non-elevated versus elevated age-related preoperative PSA. Patients and Methods: Two hundred and ninety-two patients who presented with benign histopathology after SPP, completed postoperative follow-up. Of those, 101 patients were found to have elevated preoperative PSA levels and a negative transrectal biopsy before the operation. The other group included 191 patients with preoperative PSA within age related limits. Results: PSA levels continued to be elevated in 11.8% of patients in the elevated PSA group compared with 3.5% in the non-elevated PSA group. Incidental surgical specimen cancer detection rate was 7 (6.5%) and 3 (1.5%) whereas follow-up cancer detection rate was 4 (3.9%) and zero in the elevated PSA group and non-elevated PSA group, respectively. In a logistic regression model, 2 factors were found to be statistically significant: age – the older the patient undergoing the operation, the greater was the likelihood to develop malignancy on follow-up. The second factor was the ratio between preoperative and postoperative PSA (prePSA – postPSA)/prePSA. Conclusions: This study is the first to compare long-term follow-up in patients after SPP with preoperative elevated PSA levels to those who have normal preoperative levels. The first group was found to have an increased risk incidental cancer in the surgical specimen, and of elevated PSA levels and eventually development prostate cancer upon follow-up.

Robotic radical prostatectomy in Greece: the learning curve and beyond. The initial 40 cases.

Radical prostatectomy is the treatment of choice for management of organ-confined prostate cancer. Minimally invasive treatments, as an alternative, have refined been recently by the introduction of da Vinci robotic technology which has the potential to improve surgical outcomes and reduce the steep learning curve associated with conventional laparoscopic radical prostatectomy. We report on our experience with robotic radical prostatectomy using the first da Vinci robotic system in our country. During 8months, 40 robotic radical prostatectomies were performed by a single surgical team at Athens Medical Centre (Marousi, Greece). Preoperative data collection included basic demographics, prostate-specific antigen (PSA), clinical stage, and Gleason score. Operative outcomes included operative time, estimated blood loss, and complications. Postoperative outcomes included hospital stay, pain, catheter time, pathology, PSA, return of continence, and potency. Average operative time was 186.25min with an estimated mean blood loss of 135ml. There were no intra-operative complications. Ninety per cent of the patients were discharged home on postoperative day 1 with mean haematocrit 36.7 (range 29-43). All patients reported minimal postoperative pain and resumed regular diet on the first postoperative day. Average catheter time was 6.6days (range 5-10). Early continence was observed in 47.5% of the patients, seven days after catheter removal. Continence at 1, 3, and 6months was 75, 82.5 and 95%, respectively. The overall positive margin rate was 17.5%. Ninety-five per cent of the patients had undetectable postoperative PSA levels (less than 0.1ng/ml) at a median follow-up of 6months. Our initial experience with robotic radical prostatectomy is very promising. The learning curve was approximately 10-12 cases. With a methodical approach we were able to implement the method safely and effectively in our practice, combining minimal morbidity with good oncological and functional outcomes.

Ductal feature を有する前立腺癌の臨床的検討

To determine the incidence and prognosis of prostatic ductal adenocarcinoma. From November 2002 to December 2005, we performed 122 radical prostatectomies and pelvic lymph node dissections. We further analyzed 64 cases after excluding 56 cases that had received neoadjuvant hormone therapy and two cases for which we were only able to perform limited follow-up examinations. We reviewed all of the surgical specimens and reclassified them according to the 2004 WHO classification system. We differentiated prostatic cases of ductal adenocarcinoma that were larger than 5 mm in diameter from cases of acinar adenocarcinomas. We then examined these two groups for the pathological stages of the neoplasms and the incidence of postoperative prostate-specific antigen (PSA) failure. Postoperative PSA failure was defined as a PSA value more than 0.2 ng/ml. We found eight cases (12%) of prostatic ductal adenocarcinoma among the 64 cases treated with radical prostatectomies. The mean age (+/- SD) of these patients was 65.3 (+/- 4.3) years old, and the mean PSA level (+/- SD) was 12.4 (+/- 5.4) ng/ml. Seven of the cases (11%) were mixed-type ductal adenocarcinomas, which contained acinar and ductal components. In addition, one case was identified as pure ductal adenocarcinoma. Seminal vesicle invasion was detected in four cases and lymph nodes metastases were identified in one case. During the follow-up period, four of the eight cases of ductal adenocarcinoma (50%) and twelve of the 56 cases of acinar adenocarcinoma (21%) showed postoperative PSA failure. The median follow-up period was 24 months (range: 12 to 48 months). We identified eight cases of ducal adenocarcinoma (12% of the examined cases), which suggests this disease is not as rare as previously reported. Compared to the cases of acinar adenocarcinoma, the cases of ductal adenocarcinoma were at a more advanced pathological stage and resulted in a higher rate of postoperative PSA failure. Therefore, we believe that patients that show even a limited degree of ductal adenocarcinoma should receive aggressive therapy.

Prognostic Value of Preoperative Serum Cell-Free Circulating DNA in Men with Prostate Cancer Undergoing Radical Prostatectomy

We evaluated the association of preoperative serum cell-free circulating DNA concentration in men with clinically localized prostate cancer who underwent radical prostatectomy with prostate-specific antigen (PSA) recurrence. One hundred and ninety-two men with clinically localized prostate cancer, who underwent radical prostatectomy at the Johns Hopkins Hospital and had preoperative serum available for analyses constituted our study population. All serum samples were collected before prostate biopsy or at least 4 months after prostate biopsy. The total amount of serum cell-free circulating DNA from each sample was calculated using a standard curve generated via quantitative real-time PCR. PSA recurrence was defined as a single postoperative PSA level of > or =0.2. The natural logarithm (ln) of the DNA concentration was used for statistical analyses. Of the 192 men in our study, 56 (29%) experienced PSA recurrence within the study period (median time to PSA recurrence 2 years). The median follow-up time for men free of disease at last follow-up was 3 years. The median serum cell-free DNA concentration of all men in the study was 5.3 ng/mL (mean 18.05 ng/mL; range 0.2-320 ng/mL). The mean serum DNA concentration for men who recurred and for those who did not was 3.8 +/- 34.1 and 13.7 +/- 33.6 ng/mL, respectively (P = 0.001). In a univariate analysis, ln DNA concentration was significantly associated with PSA recurrence (hazard ratio, 1.49; 95% confidence interval, 1.3-1.8; P < 0.001). In the multivariate model, ln DNA concentration was significantly associated with PSA recurrence (hazard ratio, 2.56; 95% confidence interval, 1.1-1.6; P = 0.003). Using bootstrap analyses, serum cell-free DNA concentrations > or =5.75 ng/mL were associated with an increased risk of PSA recurrence within 2 years of radical prostatectomy. Our study suggests that preoperative serum cell-free DNA concentration may be a useful prognostic biomarker for men with clinically localized prostate cancer treated with radical prostatectomy.

Prostate Cancer Metastatic to the External Auditory Canals

A 58-year-old white man with prostate-specific antigen (PSA) level of 6 ng/mL, a Gleason score of 6 (3+3), and T2a adenocarcinoma of the prostate underwent prostatectomy. On review of the pathology, the specimen contained a Gleason score of 8 (3+5) with other high-risk features. The patient had a persistently elevated postoperative PSA level and was placed on total androgen blockade. The PSA continued to increase, and the patient developed bone-only metastatic disease. The patient was treated with palliative external-beam radiation and samarium. Six months later, he presented with bilateral hearing loss and was found to have pathologic and radiographic evidence of metastatic prostate cancer to the external auditory canals. This was an unusual late finding. The patient died shortly afterward before completing palliative treatment to the area

Changes in the Serum Prostate-specific Antigen Level One Year after Transurethral Resection of the Prostate

Purpose: We wanted to investigate how transurethral resection of the prostate (TURP), for treating patients with benign prostate hyperplasia (BPH), affected the serum prostate-specific antigen (PSA) levels. Materials and Methods: The serum PSA levels were measured before and 12 months after operation in 57 patients who underwent TURP for BPH. The total prostate weight, as measured by transurethral ultrasonography (TRUS), and the weight of the surgical specimen were examined in relation to the pretreatment PSA value and the changes in the PSA levels after the operation. Results: The preoperative mean PSA density was 0.10±0.08ng/ml/cc. The postoperative serum PSA levels were decreased significantly after TURP (p=0.002). Removal of 1g of BPH tissue reduced the serum PSA levels by an average of 0.22±0.4ng/ml. The changes in the serum PSA level one year after TURP correlated with the resected chip weights [Y=0.406+0.176x (r=0.526, p<0.05)]. Conclusions: TURP caused a long term decrease in the serum PSA level. One year after TURP, the PSA levels should be expected to decrease according to the resected chip weights. (Korean J Urol 2007;48:691-695) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Prostate-specific antigen-based serial screening may decrease prostate cancer-specific mortality

Objectives To compare the preoperative characteristics, postoperative prostate-specific antigen (PSA) doubling time (DT), and prostate cancer-specific mortality (PCSM) estimates after PSA failure in men diagnosed during a screening study versus a community referral population. A PSA-DT of less than 3 months is a surrogate endpoint for PCSM. Methods From 1988 to 2002, 1492 of 9637 patients with clinically localized prostate cancer underwent radical prostatectomy and experienced PSA failure. They were either participating in a screening study (n = 841) or attended 1 of 44 community-based practices (n = 611). The distributions of PSA, Gleason score, tumor stage, and PSA-DT were compared using chi-square metric. The estimates of PCSM after PSA failure were compared using Gray’s P value. Results Compared with the community population, the annually screened men experiencing PSA failure had a lower PSA level at diagnosis (5.1 versus 9.5 ng/mL, P <0.0001), were less likely to have Gleason score 7 to 10 cancer (25.1% versus 42.1%, P <0.0001), and were more likely to have low-risk disease (64.5% versus 23.8%, P <0.0001). Furthermore, the screened cohort had a reduction ( P <0.0001) in the proportion with a PSA-DT of less than 3, 3 to 5.99, and 6 to 11.99 months and a significant increase in the proportion with a PSA-DT of 12 months or longer. After a median follow-up of 4.5 and 4.1 years after PSA failure in the screened and community cohorts, respectively, the PCSM estimates were lower ( P = 0.0002) in the screened cohort (10-year estimate 3.6% [95% confidence interval 1.3 to 5.8] versus 11.3% [95% confidence interval 5.9 to 17.4]). Conclusions Patients diagnosed by annual prostate cancer screening appeared more likely to experience an indolent PSA recurrence and less likely to die of prostate cancer after PSA recurrence compared with patients referred from the community.

Cancer-specific survival following radical prostatectomy or radiation therapy and short course hormonal therapy in men with localized, unfavorable-risk prostate cancer

4572 Background: We estimated prostate cancer-specific mortality (PCSM) rates following radical prostatectomy (RP) or external beam radiation therapy (RT) and 6 months of androgen suppression therapy (AST) in men with unfavorable-risk prostate cancer. Methods: Between 1981 and 2002, 3,240 men with intermediate- (T2b or Gleason score 7 or prostate-specific antigen (PSA) &gt; 10 to 20 ng/mL) or high-risk (T2c or Gleason score 8 to 10 or PSA &gt; 20 ng/mL) prostate cancer were treated with RP (n = 2,690) or RT+AST (n = 550) and comprised the study cohort. If PSA failure occurred, defined by a postoperative PSA level &gt; 0.2 ng/mL and rising or by the ASTRO definition following RT+AST, then men received salvage RT or life-long AST, respectively. Life-long AST was initiated if PSA failure occurred after salvage RT. Imaging of the pelvis and skeleton was negative for metastases at the time of any salvage therapy. Gray’s formulation was used to compare the cumulative incidence estimates of PCSM and to calculate the adjusted hazard ratios (HR) and associated 95% confidence intervals for initial treatment and known prognostic factors. Results: After a median follow-up time for living patients of 4.5 and 4.2 years for the RP and RT+AST cohorts, respectively, there were no significant differences in the estimates of PCSM following RP or RT+AST in men with intermediate- (p = 0.44) or high-risk (p = 0.26) disease. As shown in the Table , after adjusting for PSA level, Gleason score, and T-category, initial therapy was not significantly associated with PCSM for men with intermediate- (HR: 1.2 [95% CI: 0.3, 4.3]; p = 0.78) or high-risk (HR: 1.2 [95% CI: 0.5, 2.8]; p = 0.62) disease. Conclusion: Men with localized, unfavorable-risk prostate cancer who receive RT and short course AST as initial therapy appear to have similar PCSM rates as men who undergo initial RP followed by salvage RT and life-long AST after first and second PSA failure, respectively. [Table: see text] No significant financial relationships to disclose.