Retropubic Radical Research Articles

Changes in quality of life in first year after radical prostatectomy by retropubic, laparoscopic, and perineal approach: Multi-institutional longitudinal study in Japan

Objectives To investigate the health-related quality of life of patients who underwent radical prostatectomy performed using retropubic, laparoscopic, and perineal approaches. Methods A total of 218 men who underwent retropubic prostatectomy, 65 who underwent laparoscopic prostatectomy, and 66 who underwent perineal prostatectomy were enrolled in our survey. A baseline interview was conducted before treatment. Follow-up interviews were conducted in person at scheduled study visits 1, 3, 6, and 12 months after surgery. We measured two validated questionnaires that assessed the general and disease-specific health-related quality of life. Results The retropubic group reported substantial deterioration in physical limitations, emotional limitations, social function, and bodily pain at 1 month. The perineal group reported less bodily pain just after surgery than the retropubic and laparoscopic groups. After 6 months, however, no significant differences were found among the three groups. Postoperative urinary function remained substantially lower than the baseline level in every treatment group. Each approach with a nerve-sparing procedure showed a similar recovery profile of urinary function postoperatively. The perineal group reported no significant difference in bowel function compared with the other two groups. All of the groups continued to have decrements in sexual function. Conclusions The results of this study have demonstrated that retropubic, laparoscopic, and perineal prostatectomy have differences in the recovery of general and disease-specific quality of life in the early postoperative period. When performed by an experienced surgeon, the retropubic, laparoscopic, and perineal approaches appear to be equivalent in terms of health-related quality of life.

Robotic prostatectomy: a pooled analysis of published literature

Objective: Robotic prostatectomy has been recently added to the treatment armamentarium of localized prostate cancer. We reviewed published data on this modality with critical appraisal of outcomes and complications. Methods: A Medline® search was performed that encompassed all published articles on robotic prostatectomy. Select data on open radical retropubic (RRP) and laparoscopic (LP) prostatectomy from centers of excellence in the USA and Europe were included for objective comparison. Perioperative parameters, pathological results, including surgical margin rate, complications and postoperative continence and potency rates were reported. Advantages and shortcomings of robotic prostatectomy, and the learning curve and cost issues were also addressed. Results: Robotic prostatectomy offers advantages of minimally invasive access surgery, including enhanced visualization, decreased bleeding and transfusion rate, shorter hospital stay and faster recovery. Pathological outcomes are comparable to RRP and LP with acceptable positive margin rate. At short-term follow-up, continence and potency results appear to be equivalent to RRP and LP. The learning curve of robotic prostatectomy is faster than that of LP. Cost remains a matter of debate at the present time. Long-term cancer control results of robotic prostatectomy are still maturing. Conclusions: Robotic prostatectomy is a promising minimally invasive surgical approach for men with localized prostate cancer. Short-term clinical and pathological results compare favorably to RRP and LP.

LOW SERUM TESTOSTERONE LEVELS ARE ASSOCIATED WITH POSITIVE SURGICAL MARGINS IN RADICAL RETROPUBIC PROSTATECTOMY: HYPOGONADISM REPRESENTS BAD PROGNOSIS IN PROSTATE CANCER

It has been reported that more aggressive prostate cancer (PC) can be associated with low serum testosterone levels. The relationship between serum androgens and PC is still not completely understood. In this study we examined the association of prognostic factors in men who underwent radical retropubic (RRP) prostatectomy with low or normal total testosterone. We retrospectively evaluated 64 consecutive patients with localized PC treated with RRP between July 2002 and November 2003. PC was diagnosed by transrectal ultrasonography guided biopsy performed for either a suspicious digital rectal examination or serum prostate specific antigen greater than 4.0 ng/ml. Gleason score was determined in prostatic biopsies. Pathological TNM staging (1997), capsular perforation, seminal vesicle involvement and surgical margin status were determined in all surgical specimens. The threshold for serum total testosterone was 270 ng/dl. In all analyses p <0.05 was considered statistically significant. There were no statistically significant differences among prostate specific antigen, Gleason score (biopsy or specimen), pathological stage, capsular perforation and seminal vesicle involvement. However, patients with low total testosterone had increased positive surgical margins (p = 0.026). Patients with low total testosterone more frequently present with positive surgical margins in RRP specimens. The true association between low testosterone and poor clinical outcome in the long term needs validation in large prospective studies.

硬膜外麻酔併用腰椎麻酔下前立腺全摘除術の有用性についての検討

To evaluate the efficacy of combined lumbar spinal and epidural (CLSE) anesthesia in retropubic radical prostatectomy. Twenty consecutive patients who underwent radical retropubic prostatectomy by a single surgeon (H.K.) under CLSE anesthesia from July of 2003 to February of 2004 were selected as subjects. They were compared with 20 consecutive patients who underwent radical retropubic prostatectomy performed by the same surgeon under combined general and epidural (CGE) anesthesia from April to December of 2002. Both periods were carefully selected to exclude radical prostatectomies with intraoperative complications to evaluate genuine effects of anesthesia. For lumbar spinal anesthesia, 0.5% hyperbaric bupivacaine hydrochloride or 0.5% hyperbaric tetracaine hydrochloride (dissolved in a 10% glucose solution) was used. An epidural tube was inserted for both lumbar spinal anesthesia and general anesthesia mainly for the purpose of controlling a pain after operation. Intraoperative blood loss was significantly less in the CLSE anesthesia group compared with CGE anesthesia group (p = 0.024). Postoperative water drinking was started at 0.4 days (average) for CLSE anesthesia and at 1.1 days (average) for CGE anesthesia (p < 0.0001). Postoperative diet was begun at 0.7 days (average) for CLSE anesthesia and at 1.5 days (average) for CGE anesthesia (p < 0.0001). Compared with the CLSE anesthesia group, the mean of the highest intraoperative mean blood pressure was significantly higher in the CGE anesthesia group (p = 0.002). Intraoperative blood loss was less, intraoperative change in blood pressure was less and recovery of postoperative intestinal peristalsis was earlier in patients who underwent prostatectomy under CLSE anesthesia than in patients who underwent prostatectomy under CGE anesthesia. We believe that prostatectomy under CLSE anesthesia is more advantageous than prostatectomy under CGE anesthesia.

The Suburethral Sling for Female Stress Urinary Incontinence: A Retropubic or Obturator Approach?

Study Objective To evaluate the feasibility and safety of the obturator approach for placement of a vaginal suburethral sling indicated for women with stress urinary incontinence. Design Retrospective cohort analysis (Canadian Task Force classification IV). Setting University teaching hospital. Patients Forty-nine women suffering from stress incontinence. Intervention Analysis of the suburethral sling according to surgical approach during two consecutive periods: retropubic from January 1, 2001 through September 30, 2001, and obturator from October 1, 2001 through January 31, 2002. Measurements and Main Results Measurements and Main Results. During the study period, 25 patients underwent surgery with the retropubic approach and 24 with the obturator approach. The patient characteristics did not differ between the two groups. The obturator approach was feasible in all attempted procedures. The mean operative time was 46 minutes (range 20–90) for the retropubic approach compared with 32 minutes (range 15–50) for the obturator approach (p = .03). Two bladder injuries occurred with the former, none with the latter (although cystoscopy was not routinely performed) (p = .49). Similarly, significantly more patients in the retropubic approach group had difficulty with postoperative voiding compared with those in the obturator approach group (10 [40%] vs 2 [8%], p = .01). Only two patients, both in the retropubic group, had voiding difficulties for longer than 1 week. One month after surgery, continence results did not differ significantly between the two groups (p = .30). In the retropubic approach group, 20 (80%) of the women were cured, and substantial improvement was experienced by 5 (20%). In the obturator approach group, these figures were 20 (83%) and 3 (12.5%), respectively, with one surgical failure (4%). Those initial results were unchanged at last follow-up (mean follow-up was 13.7 ± 3 months for the retropubic approach group and 7.2 ± 2 months for the obturator approach group). Conclusion The obturator approach for suburethral slings is feasible and safe and may limit both preoperative and postoperative complications. Our short-term continence results compare well with those achieved with the retropubic approach. A randomized study is now needed to compare these two approaches.

Preservation of fecal continence and bowel function after radical perineal and retropubic prostatectomy: a questionnaire-based outcomes study.

To assess fecal incontinence rates and bowel function for radical perineal (RPP) or radical retropubic (RRP) prostatectomy patients and to compare them with a matched control group. The bowel function domain of the Expanded Prostate Cancer Index Composite (EPIC) was mailed to 150 consecutive patients who had undergone RPP (79) or RRP (71) by the same surgeon (HJK) and an age-matched control group (75). Fecal incontinence and bowel dysfunction were statistically equivalent for the study groups. There is no difference in fecal incontinence rates or bowel function when comparing RPP patients to RRP or control patients.

Risk-Factors of Recurrence after Retropubic and Perineal Radical Prostatectomy

The Authors review their own surgical series about retropubic and perineal radical prostatectomy performed in 1993–2002 ys, with particular attention for risk factors of biochemical recurrence of disease.

Laparoscopic radical prostatectomy: preliminary pathologic evaluation

Objectives Although there is increasing evidence of the interest in the laparoscopic approach for radical prostatectomy, carcinologic data, including surgical margin status, remain to be described. Methods We analyzed the oncologic results of laparoscopic prostatectomies performed during 2000. The data were compared with retropubic prostatectomies performed between 1994 and 1997 by the same two senior urologists. After matching for preoperative prostate-specific antigen level, the final analysis included 139 patients in both groups, with similar data for age, biopsy Gleason score, and number of positive biopsies. All specimens were processed with the same method of pathologic evaluation. The results were compared using either the chi-square test or Student t test. Results The mean prostate weight and rate of positive lymph nodes were similar in both groups. No statistical difference was observed in the distribution of either the radical prostatectomy Gleason score or the pathologic stage between the laparoscopic and retropubic groups. In contrast, the decrease in the rate of positive surgical margins was statistically significant in the laparoscopic approach compared with the retropubic approach ( P <0.02), particularly in localized cancers (pT2). No difference was observed in either the length or the distribution of the margin location. The rate of positive apical margins in organ-confined disease was significantly decreased in the laparoscopic group. Conclusions These results suggest that laparoscopic prostatectomy performed by trained surgeons does not lead to an increased risk of positive margins compared with the retropubic approach.

A Centralized Comparison of Radical Perineal and Retropubic Prostatectomy Specimens: Is There a Difference According to the Surgical Approach?

A Centralized Comparison of Radical Perineal and Retropubic Prostatectomy Specimens: Is There a Difference According to the Surgical Approach?

A comparison of the relative merits of radical perineal and radical retropubic prostatectomy

To compare the outcome, advantages and disadvantages of retropubic and perineal approach to radical prostatectomy, as performed by one surgeon. This unrandomized study included 138 patients who underwent either radical retropubic (RRP) or radical perineal prostatectomy (RPP), based on the specific conditions or the patient's choice; 79 patients (mean age 64.6 years) underwent RPP and 59 (mean age 61.7 years) RRP. Outcome measures included estimated blood loss, the incidence of blood transfusions, positive margins and complications, operative duration, analgesic use, days in hospital and quality of life. There was no difference in operative duration, and the incidence of positive margins or complications between the groups. The mean estimated blood loss in the RPP and RRP groups was 415 and 1,138 mL, respectively. The RPP group stayed a mean of 2.2 days less in hospital and took 2.8 days less to regain a full diet than the RRP group; the RPP group needed 1.7 days before using oral analgesics and the RRP group 3.8 days. Of patients in both groups, 85% were pad-free at one year and their overall quality of life was similar. The results of RRP and RPP are comparable; the advantages of the perineal approach include minimal blood loss, low-intensity postoperative nursing care, low analgesic use and earlier discharge from hospital.

RADICAL PROSTATECTOMY FOR PROSTATE CANCER: THE PERINEAL APPROACH INCREASES THE RISK OF SURGICALLY INDUCED POSITIVE MARGINS AND CAPSULAR INCISIONS

Purpose We compare the incidence of positive surgical margins in patients who underwent perineal or retropubic radical prostatectomy for clinically localized (stage T1, T2) prostate cancer. Materials and Methods In this retrospective, nonrandomized study we reexamined the specimens of 94 consecutive patients who underwent radical perineal (48) or retropubic (46) prostatectomy for clinically localized prostate cancer (stage T1, T2) and with pathological stage pT2 (intracapsular), pT3A (established extracapsular extension without positive margins) or pT3B (extracapsular extension with positive margins) without lymph node involvement (N0). We assessed the presence or absence of extracapsular cancer with or without positive margins, incisions of the prostatic capsule exposing cancer (surgically induced positive margins) or benign glandular tissue. Patients were followed for 3 to 66 months (mean 25) using an ultrasensitive prostate specific antigen assay with a lower detection limit of less than 0.05 ng./ml. Results The overall incidence of positive margins in cancer tissue was 56% in the perineal and 61% in the retropubic group, and biochemical failure-free survival was 67% each. However, surgically induced positive margins in patients with organ confined disease were more frequent in the perineal than retropubic group (43 versus 29%, p <0.05) and associated with a 37% risk of biochemical failure (prostate specific antigen greater than 0.1 ng./ml.) at mean followup. In addition, capsular incisions exposing benign tissue were more frequent in the perineal than retropubic group (90 versus 37%, p <0.05) irrespective of pathological stage. Conclusions Although overall positive margins and biochemical failure rates are similar or identical for the perineal and retropubic approaches for organ confined prostate cancer, the perineal approach is associated with a significantly higher risk of capsular incisions and surgically induced positive margins and, thus, a higher risk of biochemical failure.

Post-Prostatectomy Urinary Incontinence: Response to Behavioral Training

Urinary incontinence after prostatectomy can be psychologically and socially disabling. We reviewed our experience with 27 patients who were incontinent between 5 and 198 months after either radical retropubic, total perineal or transurethral prostatectomy. These patients were entered into our bladder behavior clinic, which was administered by nursing staff with physician supervision. Patients were strongly encouraged to discontinue the incontinence devices, and were then evaluated for the type and extent of incontinence. Perineal exercises were demonstrated in detail, tested for their correct use via simultaneous rectal and abdominal examination, and applied to the pattern of incontinence. Patients were evaluated frequently for compliance and their progress was followed with instruction repeated as needed. Pharmaceutical agents were not used.Among the 24 patients evaluable over-all improvement in the number of incontinent episodes was 56.6% (p <0.001). Two patients (8.3%) achieved total continence, 10 (42%) improved greatly, 4 showed moderate improvement and 8 (33%) showed essentially no change. Transurethral and perineal prostatectomy patients improved by 74 and 61%, respectively, versus only 33% in the radical retropubic group (p = 0.14). In addition, patients who previously underwent transurethral resection before total prostatectomy did worse (18%) than did those who did not (67%).We conclude that a significant number of patients who are incontinent after prostatectomy (especially those without a prior transurethral resection) can improve dramatically with a behavioral training program that provides a strong support system.

Incidence of surgical margin involvement in various forms of radical prostatectomy

The pathologic specimens of 64 patients who underwent radical prostatectomy for clinical Stage A or B carcinoma of the prostate were reviewed retrospectively for surgical margin involvement with cancer. Fourteen of the operations were performed by the radical transperineal method, 30 by the standard radical retropubic approach, and 20 by the nerve-sparing radical retropubic technique. Seventy-eight percent of the radical transperineal group had resection margin involvement, as opposed to 30 percent of the standard radical retropubic cases, and 45 percent of the nerve-sparing radical retropubic cases. The average tumor burden of the transperineal group was larger than that of the other two groups. Resection margin involvement in all groups was associated with a higher Gleason histologic score. No significant difference was noted between the two retropubic groups in terms of resection margin involvement (P = 0.28), suggesting that nerve-sparing radical retropubic prostatectomy does not compromise the surgical goal of radical prostatectomy for carcinoma over that of the standard radical retropubic prostatectomy.

Metabolic effects of prostatectomy.

Transurethral resection syndrome (TURS), complicating transurethral resection of the prostate (TURP) has been ascribed to hyponatraemia but reports have indicated that hyperammonaemia following metabolism of glycine can be the main cause. Prospective data has been collected on 96 prostatectomy patients (82 TURP and 14 retropubic). The retropubic group showed no significant postoperative change in the serum sodium or plasma ammonia. Of the TURP group, no TURS occurred although hyponatraemia was noted in 32 patients. The weight of prostate resected, the volume of glycine used, the time taken and the plasma ammonia levels were not significantly different in the normonatraemic or hyponatraemic groups. In severely hyponatraemic patients (13 out of 32 with a 10 mmol/l, or greater, decrease in serum sodium) there was a significant rise (P less than 0.05) in plasma ammonia, 1 or 4 h post TURP, which had decreased by 24 h. There was a highly significant increase in serum glycine level in the hyponatraemic compared with the normonatraemic group (P less than 0.001). There was no correlation between serum glycine and plasma ammonia levels in the normonatraemic or hyponatraemic group. There were nine patients with post TURP plasma ammonia levels greater than 100 mumol/l (mean 254) who experienced no mental confusion: six of these patients were hyponatraemic. The weight of prostate resected (mean 26 g), volume of glycine used (mean 181) and operation time (mean 39 min) were all relatively low. Subsequently, TURS has occurred in a patient, with severe hyponatraemia and hyperglycinaemia but no hyperammonaemia. This study shows that hyperammonaemia does not always correlate with hyponatraemia or hyperglycinaemia, and high plasma ammonia levels can occur in the absence of TURS.