Postoperative Prostate-specific Antigen Research Articles

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).

Adjuvant versus salvage radiation therapy for prostate cancer and the risk of death

To investigate whether salvage radiation therapy (RT) for prostate-specific antigen (PSA) failure can provide the same result as adjuvant RT, which decreases the risk of all-cause mortality (ACM) for men with positive margins (R1), or extra-capsular or seminal vesicle extension (pT3). We studied 1638 men at Duke University who underwent radical prostatectomy for unfavourable-risk prostate cancer and whose postoperative PSA was undetectable. Cox regression was used to evaluate whether salvage vs adjuvant RT in men with a rapid (<10 months) or slow (≥10 months) PSA doubling time (DT) was associated with the risk of ACM, adjusting for adverse features (pT3, R1, Gleason score 8-10), age, preoperative PSA level, comorbidity and hormonal therapy use. Despite fewer men with two or more adverse features (61 vs 82%; P=0.016), salvage for a rapid PSA DT vs adjuvant RT increased the risk of ACM [adjusted hazard ratio (AHR)=3.42; 95% confidence interval (CI)=1.27-9.20; P=0.015]. There was no difference (AHR=1.39; 95% CI=0.50-3.90; P=0.53) in the risk of ACM among men who received salvage for a slow PSA DT or adjuvant RT. Nearly all (90%) men with a slow PSA DT had Gleason score ≤7 and the majority (59%) had at most pT3 or R1 disease. Radiation therapy after PSA failure as compared with adjuvant RT was not associated with an increased risk of ACM in men with Gleason score ≤7 and pT3R0 or pT2R1 disease.

IJU this issue

This issue contains seven Original Articles, four Editorial Comments, two Short Communications, and one Skills and Pitfalls. In general, chromophobe renal cell carcinomas (chRCC) are believed to have a more favorable prognosis than conventional RCC. Lee et al. (ChunCheon, Korea) analyzed the characteristics and prognostic importance of chRCC based on a large, multicenter experience. Surprisingly, the non-metastatic chRCC showed equivalent oncological outcomes compared to the conventional RCC. It is well recognized that T1 bladder cancer can be life-threatening in some cases. Using the cancer registration database of the Japanese Urological Association, Okajima et al. (Nara, Japan) found that non-papillary tumor appearance, positive urinary cytology and a tumor size greater than 3 cm were independent prognosticators, and claimed that these factors should be included in order to enable the assessment of risk criteria in cancer death from T1 bladder cancer. As not all men necessarily benefit from early secondary treatment for biochemical recurrence (BCR) after radical prostatectomy (RP), it is critical to properly select patients for adjuvant therapies in order to minimize side-effects and maximize their benefits. Moreir et al. (Durham, USA) developed and externally validated a new nomogram incorporating postoperative prostate-specific antigen nadir and other well-established predictors of BCR. Although high-intensity focused ultrasound (HIFU) is a minimally invasive therapy for prostate cancer (CaP), the most common adverse event reported during follow up is the formation of bladder outlet obstruction. Sumitomo et al. (Tokorozawa, Japan) introduced transurethral resection of the prostate immediately after HIFU treatment of CaP, which improved post-treatment urinary status without causing additional morbidity. Antimuscarinic agents have long been the drugs of choice for pharmacological treatment of overactive bladder. Using video urodynamics, Watanabe et al. (Mibu, Japan) demonstrated the efficacy of tolterodine ER for the treatment of neurogenic detrusor overactivity and/or low compliance bladder. Intracytoplasmic sperm injection has allowed patients with very few sperm to achieve fertilization, which leads to the possibility of cryopreservation of semen, even from patients with very low sperm counts. Bak et al. (Seoul, Korea) investigated the fate of patients with severely impaired semen status and warned that patients with severe oligozoospermia are at high risk of becoming azoospermic and hence sperm freezing should be encouraged as early as possible for this population. Electrosurgery is one of the most commonly used energy systems in transurethral prostate and bladder surgery. Chung et al. (Jeonju, Korea) identified several toxic and carcinogenic gases (1,3-butadiene, vinyl acetylene, and acrylonitrile) generated during transurethral resection of the prostate and vaporization. This important finding confirms the need for protective methods to be developed. Okegawa et al. (Tokyo, Japan) reported the usefulness of alternative hormonal therapy for treating resistance to first-line hormonal therapy, adding further evidence to the growing literature in this field. Prepubertal testicular tumors are different from their postpubertal counterparts in histopathological type and clinical behavior. Based on their 20-year experience, Hisamatsu et al. (Kobe, Japan) proposed a treatment algorism for this rare tumor in children. Complete hemostasis after transection of the dorsal vein complex (DVC) is an extremely important step during the course of radical prostatectomy. Sasaki et al. (Tokyo, Japan) found that bleeding from the DVC is easily controlled without suture ligation through a combination of a modest pneumoperitoneum with pinpoint coagulation of one or two small arteries that are found in the superficial layer of the complex. This simple technique can also be applied to the recent robot-assisted radical prostatectomy.

Impact of postoperative prostate‐specific antigen disease recurrence and the use of salvage therapy on the risk of death

We read with interest the article by Choueiri et al on the impact of salvage therapy on survival in men with biochemical recurrence (BCR) after prostate cancer surgery.1 They found, as had we,2, 3 that survival after BCR was better in men with PSA doubling time (PSADT) ≥6 months, and also in men who received salvage therapy. In our study, however, we found that the survival benefit of salvage radiotherapy or salvage androgen deprivation therapy (compared with no additional therapy) was only significant among men with PSADT <6 months; among men with PSADT of 6 months or greater salvage therapy did not significantly improve survival.2, 3 This appeared to be because men with PSADT ≥6 months had very good survival regardless of additional therapy, so the incremental benefit of salvage therapy was not significant. Was the effect of salvage hormonal or radiation therapy similarly dependent on PSADT in the study by Choueiri et al? Also, the article did not explicitly define the timing of administering salvage therapies, which begs the question: did salvage treatment include hormonal therapy administered at the time of metastases? Bruce J. Trock PhD*, Patrick C. Walsh MD*, * Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland.

Postoperative prostate‐specific antigen nadir improves accuracy for predicting biochemical recurrence after radical prostatectomy: Results from the Shared Equal Access Regional Cancer Hospital (SEARCH) and Duke Prostate Center databases

We previously showed that prostate-specific antigen (PSA) nadir after radical prostatectomy (RP) significantly predicts biochemical recurrence (BCR). Herein, we sought to explore the effect of including PSA nadir into commonly used models on their accuracy to predict BCR after RP. This was a retrospective analysis of 943 and 1792 subjects from the Shared Equal Access Regional Cancer Hospital (SEARCH) and Duke Prostate Cancer (DPC) databases, respectively. The discrimination accuracy for BCR of seven previously published models was assessed using concordance index and compared with and without adding PSA nadir level in SEARCH. Using data from SEARCH, we developed a new nomogram incorporating PSA nadir to other known predictors (preoperative PSA, pathological Gleason score, PSA nadir level, surgical findings, prostate weight, body mass index and race) of BCR and externally validated it in the DPC. In SEARCH, the mean concordance index across all seven nomograms was 0.687. After the inclusion of PSA nadir, the concordance index increased by nearly 7% (mean=0.753). The concordance index of the new nomogram in SEARCH was 0.779 (bias-corrected=0.767), which was 5% better than the next best model. In DPC, the new nomogram yielded a concordance index of 0.778. The addition of postoperative PSA nadir to commonly used nomograms increased their accuracies by nearly 7%. Based upon this, we developed and externally validated a new nomogram, which was well calibrated and highly accurate, and is a potentially valuable tool for patients and physicians to predict BCR after RP.

Lifelong Yearly Prostate Specific Antigen Surveillance is Not Necessary for Low Risk Prostate Cancer Treated With Radical Prostatectomy

Many patients undergoing radical prostatectomy in the prostate specific antigen era have a low risk of recurrence. Aggressive postoperative prostate specific antigen surveillance is costly and anxiety provoking. In this study we investigate the need for yearly prostate specific antigen measurements in patients with surgically treated low risk prostate cancer. We identified 2,219 patients who underwent radical prostatectomy between 1994 and 2004 for low risk localized prostate cancer. Low risk was defined as prostate specific antigen less than 10 ng/ml, pathological stage pT2c or less, Gleason score 6 or less, negative lymph nodes and negative surgical margins. Patients who underwent neoadjuvant or adjuvant therapy were excluded from analysis. Biochemical failure was defined as a prostate specific antigen greater than 0.4 ng/ml and prostate specific antigen values less than 0.15 ng/ml were considered undetectable. Biochemical failure rates were calculated according to the duration of the prostate specific antigen-free period after radical prostatectomy. A total of 142 (6.4%) patients experienced biochemical failure during the course of the study. The risk of biochemical failure decreased with increasing duration of the prostate specific antigen-free interval. For example 1, 3 and 5-year biochemical failure rates calculated at surgery were 1.8%, 4.2% and 6.3%, respectively. For patients with undetectable prostate specific antigen measurements 5 years after surgery the 1, 3 and 5-year biochemical failure rates were 0.0%, 0.7% and 1.3%, respectively. In addition, 1-year biochemical failure rates were 0.2%, 0.4%, 0.0% and 0.0% after a prostate specific antigen-free period of 1, 3, 5 and 10 years, respectively. The risk of biochemical failure is inversely proportional to the duration of the prostate specific antigen-free interval after radical prostatectomy in low risk patients. Biochemical failure 1 year after an undetectable prostate specific antigen is uncommon, especially after a prostate specific antigen-free period of 3 years. These data suggest that annual prostate specific antigen measurements are unnecessary, especially after a prostate specific antigen-free interval of 3 years. Prostate specific antigen measurements every 2 years should capture the majority of low risk patients who experience progression.

Active Hydrodissection Might Optimize Cryosurgical Ablation of the Prostate

To produce lower temperatures safely in the prostate, and better protect the rectum , as well as maximize the technique of cryosurgical ablation to better eradicate prostate cancer. A total of 10 consecutive patients underwent total, subtotal, or focal cryosurgical ablation, with saline hydrodissection. We found lethal prostate temperatures and safer rectal temperatures. One patient developed a very small rectourethral fistula that healed with catheter drainage alone, prompting a revised technique. The prostate-specific antigen values at short follow-up were very low. Temperatures of -10°C to -76°C were achieved outside the prostate at the neurovascular bundle. Post-operative prostate-specific antigen values were 0.10 to 3.4 if total or focal therapy, respectively, was used. A small rectal fistula healed with catheter drainage alone. This technique appears to hold great promise and should be investigated further in a larger group of patients with longer follow-up.

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.

Benign prostate glands at the bladder neck margin in robotic vs open radical prostatectomy

To compare the prevalence and extent of benign glands at the bladder neck (BN) margin in a large population undergoing open retropubic radical prostatectomy (RRP) and robotic-assisted laparoscopic RP (RALP), as RALP was previously suggested to be associated with a higher rate of benign glands at the surgical margin than RRP. From 2005 to 2008, 137 RRP and 152 RALP were performed by one surgeon. Pathology slides were re-reviewed while unaware of origin to examine the extent of benign glands at the BN margin (minimal, moderate, or extensive). Statistical analysis was used to assess the prevalence and extent of benign glands in the two procedures. Benign prostatic glands were present at the margins in 89 (58.2%) RALP and 57 (41.6%) RRP specimens (P= 0.005). There were also a significantly greater extent of benign glands in RALP vs RRP (P= 0.031). After multivariate adjustment for prostate-specific antigen (PSA) level, clinical stage, and biopsy Gleason score, RALP maintained a significant association with both the presence (P= 0.019) and extent (P= 0.018) of benign glands at the BN. Two patients with organ-confined disease (no cancerous margins) with benign glands at the BN margin had an initially high postoperative PSA level. Benign prostate glands were present at the BN margin in a greater proportion of RALP than RRP specimens, possibly due to differences in the surgical approach to BN dissection. Additional study is necessary to determine the long-term biological significance, if any, of these histological differences.

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 ...

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.

Preoperative Prostate Specific Antigen Doubling Time is Not a Useful Predictor of Biochemical Progression After Radical Prostatectomy

Postoperative prostate specific antigen doubling time may be used as a surrogate for prostate cancer specific mortality in patients with biochemical recurrence after radical prostatectomy. Less is known about the usefulness of preoperative prostate specific antigen doubling time for the initial prediction of prostatectomy outcomes. Preoperative prostate specific antigen doubling time was calculated in 1,208 men from a large prostate cancer screening study who were treated with radical prostatectomy. We examined the relationship of prostate specific antigen doubling time with tumor features and biochemical progression-free survival. Overall prostate specific antigen doubling time was associated with nonorgan confined disease (OR 0.996, 95% CI 0.992-0.999, p = 0.013) but not with biochemical progression (HR 1.000, 95% CI 0.998-1.001, p = 0.66). Using previously published 18 and 36-month thresholds for prostate specific antigen doubling time there was no significant relationship between doubling time and specific adverse pathological features or biochemical progression. Using the concordance index prostate specific antigen doubling time did not enhance the prediction of biochemical progression beyond that achieved by a model with prostate specific antigen, clinical stage and biopsy Gleason score. In our series of men with newly diagnosed, clinically localized prostate cancer shorter preoperative prostate specific antigen doubling time was associated with nonorgan confined disease but not with biochemical progression after radical prostatectomy. All calculations of prostate specific antigen kinetics may not be equivalent. Caution should be exercised when using prostate specific antigen doubling time in the pretreatment setting.

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Prostate-specific antigen (PSA) monitoring after radical prostatectomy is far from simple and straightforward in patients with a detectable PSA. Not only can this confusion cause undo stress for clinicians and patients, but also misinterpretation of PSA values may potentially result in a worse clinical outcome from overtreatment or undertreatment with secondary therapy. The objective of the present study was to clarify the interpretation of postoperative PSA in men with biochemical recurrence after radical prostatectomy. Editorial CommentUrologyVol. 75Issue 2PreviewIn the setting of defining PSA recurrence (PSAR) after radical prostatectomy (RP), on the surface, it would seem easy. The prostate is gone and the PSA should be gone. However, in the real world practice setting it is commonly confounded by definitions of recurrence, residual cancer cells vs benign prostate tissue, miscommunications or misunderstanding, and ultrasensitive PSA vs standard PSA measurements. Full-Text PDF

Stage pT0 After Radical Prostatectomy With Previous Positive Biopsy Sets: A Multicenter Study

We analyzed preoperative data, pathological results and followup of pT0 tumors after radical prostatectomy for prostate cancer diagnosed on previous positive biopsy. At 6 centers a total of 30 of 7,693 radical prostatectomy specimens were classified as pT0 despite prior biopsy proven prostate cancer. No patients were diagnosed after transurethral prostate resection or received neoadjuvant hormonal treatment. All biopsy cores and radical prostatectomy specimens were reanalyzed by a second pathologist. Followup comprised clinical examination and postoperative prostate specific antigen assay at 1 and 3 months, and every 6 months thereafter. Median patient age was 63 years (range 46 to 73). Median preoperative prostate specific antigen was 7.4 ng/ml (range 1.3 to 23). Of the cases 24 were T1c and 6 were T2a. The median number of biopsy cores was 10 (range 6 to 21) with 1 positive (range 1 to 4). On biopsies median tumor length was 1 mm (range 0.3 to 18) and there was tumor in 11.1% (range 3.4% to 64%). In 25 cases (83.3%) there was only 1 positive biopsy. Gleason score was 3 + 3 in 23 cases and less than 6 in 5 with grade 4 in 2. Only 9 cases filled all nonsignificant tumor criteria. Median specimen weight was 61 gm (range 40 to 160). At a median 82-month followup (range 14 to 226) there was no biochemical progression. After biopsy proven cancer pT0 prostate cancer is an unpredictable pathological finding. Despite its excellent prognosis it has medicolegal repercussions that justify DNA based tissue analysis. There is no evidence that finding focal cancer after extensive prostate resection changes patient prognosis and postoperative treatment.

Evaluation of the outcome of laparoscopic radical prostatectomy by a single surgeon: experience with an initial 30 cases.

Objective: We carried out this study to clarify whether operative methods of laparoscopic prostatectomy (LRP) could become a standard therapy. The purpose was to evaluate the technical feasibility, oncologic effectiveness and perioperative and postoperative morbidity of LRP performed by a general urologist.Patients and Methods: Between June 2004 and May 2006, 30 patients with clinically localized prostate cancer consecutively underwent LRP by a single surgeon. Oncologic data were assessed by histopathological examination and by postoperative prostate-specific antigen (PSA) levels.Results: Complete laparoscopic removal of the prostate and seminal vesicles was achieved in all 30 patients. The average operation time was 250.9 min (range, 168 to 394 min). The total positive surgical margin rate was 20.7% (6 of 29 cases), with a total PSA recurrence rate was 23.3% (7 of 30 cases), but the frequencies tended to be decreased in the later phase cases. Perioperative complications were encountered in 5 patients; four of these patients were in the initial 10 cases. Two of the 30 cases (6.7%) required a blood transfusion (first case and 11th case). There were three surgical complications, one ureter injury, one rectal injury and one sigmoid serosal injury. The catheter duration intervals were reduced in the later cases.Conclusions:From our experience with one surgeon, with whom perioperative complications were concentrated in the initial 10 cases, we conclude that LRP should be performed by experienced surgeons after intensive training.

External Validation of a Preoperative Nomogram for Prediction of the Risk of Recurrence After Radical Prostatectomy

To test the validity of an updated version of the preoperative Kattan nomogram for prediction of recurrence after radical prostatectomy (RP), published by Stephenson et al. We relied on clinical and postoperative prostate-specific antigen follow-up data of 1978 patients treated with open RP at our institution between 1992 and 2006. The accuracy of the nomogram-derived recurrence-free survival predictions were separately tested at 1 to 10 years after RP. Moreover, the relationship between the nomogram-predicted recurrence-free survival rate and the observed recurrence-free survival rate was graphically explored in calibration plots. Median follow-up of censored patients was 32 months. For nomogram-derived recurrence-free survival predictions at 1 to 10 years, the accuracy of the nomogram ranged from 70% to 76%. The calibration between the predicted and observed recurrence-free survival rates was good at 1 and 2 years after RP. However, at all other examined time points, departures from ideal predictions were recorded. Our findings indicate that the preoperative biochemical recurrence nomogram reported by Stephenson et al. can be applied to European patients with good accuracy. However, its calibration was only suboptimal for predictions made 3 or more years after RP, with a tendency to overestimate the probability of recurrence-free survival. This potential limitation should be considered when this tool is applied to European patients.

Prostatic-specific Antigen Velocity After Holmium Laser Enucleation of the Prostate: Possible Predictor for the Assessment of Treatment Effect Durability for Benign Prostatic Hyperplasia and Detection of Malignancy

To evaluate the prostate-specific antigen velocity (PSAV) as an indicator for effectiveness and durability of size reduction after holmium laser enucleation of the prostate (HoLEP). Additionally, PSAV monitoring in the detection of prostate cancer was also evaluated. Between 1998 and 2006, we reviewed the prostate-specific antigen (PSA) data of 335 men who underwent HoLEP and had a complete PSA data including preoperative PSA, postoperative PSA (reset), and a minimum of 2 annual PSA readings after PSA reset. PSAV was calculated by 3 methods--simple arithmetic method, linear regression method, and rate method. In the benign group, the mean PSA dropped from 5.44 to 0.91 ng/mL (P <0.001). The prostate cancer patients who were newly discovered in the follow-up period had significantly higher baseline PSA (P = .032) and significantly lower PSA reduction than that of the benign group (75.39% vs 47.49%, P <.001). PSAV was calculated by 3 different methods and produced identical results; however, linear regression method produced significantly lower estimates at 7 years. In the malignant group, the mean PSAV at 1 and 3 years was higher than that of the benign group (1.28 vs 0.13 and 2.4 vs 0.09, P <0.022, 0.001, respectively). HoLEP results in a significant reduction in PSA that remained at lower levels during follow-up, suggesting that the glandular size reduction after HoLEP is durable. Monitoring of PSAV is important in long-term follow-up of patients for prostatic carcinoma detection after prostatic surgery.

Radical Laparoscopic Salvage Prostatectomy: Medium-Term Functional and Oncological Results

To analyze the surgical, functional, and oncological results of radical laparoscopic salvage prostatectomy in local postradiotherapy recurrence. Between May 2005 and April 2007, we treated nine patients with radical laparoscopic salvage prostatectomy. Five patients had received prior treatment with brachytherapy and the other four with external radiotherapy. The average age of the patients was 59.3 years (range 51-68). The average preoperative prostate-specific antigen was 9.1 ng/mL (range 2.6-30). The average follow-up period was 26.8 months (range 15-39). The average duration of surgery was 170 minutes (from 120 to 240). There was no need to resort to open surgery or transfusions. There were no cases of rectal injuries. Four cases were pT2c, 1 pT3a, 3 pT3b, and 1 pT4a. The Gleason score was 7 in three cases, 8 in two cases, and 9 in another four. Two patients had nodal metastasis. Postoperative prostate-specific antigen was undetectable in seven of the nine patients. Two patients experienced biochemical recurrence 16 and 13 months after the surgery. After a minimum follow-up period of 15 months, they were free from recurrence. There were no cases of urethrovesical anastomotic stenosis. Three patients manifested severe incontinence (more than two diapers per day), which was corrected in two cases by implanting an artificial sphincter. The other six patients required 0 to 1 pads/day. Before the surgery, only one of the five potential patients maintained his erectile function. Radical laparoscopic salvage prostatectomy is a complex technique that seems to allow attaining high and long-lasting rates of biochemical remission in patients with local postradiotherapy recurrence. Although there is less morbidity in our series in comparison with the anastomotic stenosis and rectal injuries rate published in radical retropubic salvage prostatectomy, more extensive comparative studies are required to confirm this fact.

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.

Editorial Comment

The authors compared prostate-specific antigen (PSA) levels before and after simple prostatectomy between those who were and were not diagnosed with prostate cancer (CaP). The data presented provide the practicing urologist with helpful information for assessing the risk of CaP after simple prostatectomy using PSA and PSA changes. ReplyUrologyVol. 74Issue 1PreviewWe agree with the notion initially presented by Dr. Walsh that the utility of prostate-specific antigen (PSA) measurement after undergoing surgical intervention for the treatment of benign prostatic hyperplasia (BPH) might represent a more sensitive tool to distinguish the presence of prostate cancer (CaP) because of the removal of confounding benign adenoma. However, different surgical procedures differ in their efficacy in removing adenoma. Thus, each procedure used for the treatment of BPH might have its own unique postoperative PSA nadir secondary to the amount of residual benign disease. Full-Text PDF Postoperative PSA and PSA Velocity Identify Presence of Prostate Cancer After Various Surgical Interventions for Benign Prostatic HyperplasiaUrologyVol. 74Issue 1PreviewTo determine whether prostate-specific antigen (PSA) values can distinguish those with prostate cancer (CaP) from those with histologic benign prostatic hyperplasia (BPH) only after surgical intervention. Prostatic adenoma inevitably remains after BPH surgery; therefore, patients remain at risk of developing CaP. Although the PSA level can be used for CaP screening in this population, it might be influenced by the efficacies of different BPH procedures. Full-Text PDF