Time Of Radical Retropubic Prostatectomy Research Articles

Improvement of recurrence-free survival after radical prostatectomy for locally advanced prostate cancer in relation to the time of surgical intervention

Objective: to comparatively estimate the frequency of a positive surgical margin and 5-year biochemical recurrent-free survival (BRFS) rates in patients with locally advanced prostate cancer in relation to the time of radical retropubic prostatectomy. Subjects and methods. The investigation enrolled 274 patients with prostate cancer (pT3-4N0-1M0) who were divided into 2 groups of 68 and 20 patients operated on in 1997 to 2006 and 2007 to 2012, respectively. Two surgeons made surgical interventions by the standardized procedure. The 5-year BRFS rates were estimated using the Kaplan-Meier method and log-rank test. A biochemical recurrence was defined as a prostatespecific antigen level of t 0.2 ng / ml in 2 consecutive measurements or as the initiation of adjuvant therapy. Results. The detection rate of a positive surgical margin decreased from 55.9 % in 1997–2006 to 37.9 % in 2007–2012 (p = 0.01); the 5-year recurrence-free survival rates were 38.8 % versus 66.2 % (p < 0.001). Conclusion. These changes would probably be a result of surgeons» better experience and improved surgical techniques in the course of time.

Incidence, distribution, and outcomes of node positive patients at radical prostatectomy: Manitoba Prostate Center experience.

162 Background: Pelvic lymph node dissection at the time of radical retropubic prostatectomy (RRP) varies among surgeons and institutions. Differences focus on candidacy for node dissection and the limit of dissection. Standard lymph node dissection is typically above the obturator nerve to external iliac vessels. We analyzed our local experience of lymph node metastases at time of surgery. Methods: Data from the Manitoba Prostate Center were collected on consective patients undergoing RRP from January 2003 to June 2013 by two urologists with subspecialty training in oncology. Information extracted includes age, prostate-specific antigen (PSA), biochemical recurrence characteristics, and biopsy and pathological results. Results: Four hundred twenty consecutive patients comprised the data set and of whom 411 underwent a RRP and nine aborted prostatectomies. Average age of patients was 60 with an average preoperative PSA of 11. Overall lymph node metastases rate is 16.1%. Of the N1 patients, average number of positive nodes was 2.3. Average nodes removed for all patients were 13.4. Positive nodes on the right were found 53% of the time and 47% on the left. Locations of nodes are as follows: right external iliac, obturator, and hypogastric, 12%, 6%, and 19%, respectively; and for left external iliac, obturator, and hypogastric 9%, 3%, and 16%, respectively of all total nodes. One node was identified as other, and one surgeon sent packets as right pelvic and left pelvic with positive nodes 16% and 19% of all total positive nodes respectively. When looking at zones of a pelvic lymph node dissection separately, 54% are hypogastric, 13% obturator, and 33 external iliac. With an average of 37 months follow-up two patients with N1 disease died and only one from prostate cancer. Seventy nine percent had biochemical recurrence. Median time to treatment for biochemical recurrence was 4.5 months (0 to 33 months) with a median PSA of 0.28. Conclusions: This contemporary series of pelvic lymph node dissection with RRP represents high lymph node metastases (16%) relative to literature. Performing a limited pelvic lymph node dissection would under stage 54% of our patients. Despite high biochemical recurrence only one patient died of prostate cancer.

Inguinal hernia after radical retropubic prostatectomy: risk factors and prevention

The two most frequently occurring and well-described complications of radical retropubic prostatectomy (RRP) for prostate cancer are incontinence and impotence. Inguinal hernia (IH) has, over the last decade, emerged as an additional complication, with an estimated incidence of 15-20% after RRP. IH is a common lesion in men aged between 50 and 70 years with or without prostate cancer, and the literature indicates that annual incidence is somewhere between 0.5% and 1% in the general male population. Important risk factors for the development of post-RRP IH are previous IH surgery, increasing age, and low BMI. However, subclinical IH at the time of RRP and a lower midline incision seem to be the most important causative factors. Prophylactic procedures and, in the case of clinically detectable IH lesions, concurrent repair during RRP are advocated. Reports on alternative approaches to RRP, such as minilaparotomy RRP, laparoscopic radical prostatectomy (including robot-assisted procedures) and radical perineal prostatectomy have indicated low rates of postoperative IH. The risk of developing IH after prostatectomy should be part of the preoperative risk assessment when making treatment decisions for patients with prostate cancer.

Post-Radical Prostatectomy Inguinal Hernia: A Simple Surgical Intervention can Substantially Reduce the Incidence—Results From a Prospective Randomized Trial

After radical retropubic prostatectomy a postoperative inguinal hernia develops in 15% to 20% of patients. We investigated whether a simple prophylactic procedure during radical retropubic prostatectomy would reduce this incidence. A total of 294 consecutive patients scheduled for radical retropubic prostatectomy at our clinic were prospectively included in the study. Patients with a present inguinal hernia or a previous inguinal hernia surgery were not included in the analysis. The subjects were randomized for side of prophylactic intervention (left or right). At radical retropubic prostatectomy a nonresorbable figure-of-8 suture was placed lateral to the internal ring of the inguinal canal and the spermatic cord on either side according to outcome of the randomization. Patients were followed at regular followup visits at the clinic. At the end of the study all patients were invited for a final interview and examination by an independent examiner who was unaware of the side of intervention. Of the patients 86% (254) showed up for the final examination. The cumulative inguinal hernia incidence was 3.5% on the intervention side and 9.1% on the control side (log rank Mantel-Cox p = 0.011). There were no serious adverse events, and no increase in postoperative discomfort in the groin and testicular region on the intervention side. The procedure added 5 to 10 minutes to the duration of surgery. The prophylactic procedure was simple and safe to perform, and it decreased the risk of postoperative inguinal hernia formation by 62%. We believe it should be considered for patients undergoing radical retropubic prostatectomy.

A Novel Technique to Prevent Postradical Retropubic Prostatectomy Inguinal Hernia: The Processus Vaginalis Transection Method

To present a novel technique to prevent inguinal hernias after radical retropubic prostatectomy (RRP). The incidence of inguinal hernia after RRP has been reported to occur in the range 12%-21%. Indirect hernias are more common than direct hernias after RRP. A total of 569 Japanese patients with prostate cancer underwent antegrade RRP between January 2001 and February 2007. Since February 2006, 138 patients underwent procedures for concurrent inguinal hernia prevention at the time of RRP. For hernia prevention, the processus vaginalis was ligated close to the peritoneal cavity and transected. The remaining 431 patients who underwent the same RRP procedures without hernia prevention were considered control group. The incidence rates of postoperative inguinal hernia in the 2 groups were statistically compared. An inguinal hernia developed postoperatively in 105 (24%) of the 431 control patients during follow-up of median 42 months. Hernia-free survival rates were 87%, 81%, and 77%, for 1-, 2-, and 3-year, respectively. By contrast, 2 of the 138 patients (1.4%) who underwent hernia prevention developed an inguinal hernia during follow-up of median 24 months. Hernia-free survival rates were both 99% for 1- and 2-year (P <.0001). The hernia prevention procedure added approximately 10 minutes to the surgery time. There were no significant complications associated with the hernia prevention procedure. Our results suggest that this prophylactic measure is safe and effective to prevent post-RRP inguinal hernias. However, a longer follow-up period is needed to confirm the results.

Incorporation of Anterior Rectus Fascial Sling into Radical Retropubic Prostatectomy Improves Postoperative Continence

Aim: To determine the impact of rectus fascial sling suspension at the time of radical retropubic prostatectomy (RRP) on postoperative continence status. Patients and Methods: A total of 86 patients underwent RRP for clinically localized prostate cancer. Out of 86 patients, a rectus fascial sling procedure was incorporated into RRP in 40 randomly selected patients (group 1). The remaining 46 patients underwent standard RRP without any suspension operation (group 2). Results: The incontinence rates were 17.5 and 43.5% for groups 1 and 2, respectively (p = 0.010). Incontinence degrees for each group were statistically significant (p = 0.03). The mean time to achieve full continence was 1.4 ± 2.2 (0–11) and 3.8 ± 3.8 (0–12) months for groups 1 and 2, respectively (p = 0.026). Conclusion: Our results showed that incorporation of an anterior rectus fascial sling into RRP is a reasonable and efficient way of achieving improved rates of postoperative continence.

Preoperative predictors of blood loss at the time of radical prostatectomy: results from the SEARCH database

The literature contains conflicting data on preoperative predictors of estimated blood loss (EBL) at radical retropubic prostatectomy (RRP). We sought to examine preoperative predictors of EBL at the time of RRP among patients from the SEARCH database to lend clarity to this issue. A total of 1154 patients were identified in the SEARCH database who underwent RRP between 1988 and 2008 and had EBL data available. We examined multiple preoperative factors for their ability to predict EBL using multivariate linear regression analysis. Median EBL was 900 ml (s.d. 1032). The 25th and 75th percentile for EBL were 600 and 1500 ml, respectively. EBL increased significantly with increasing body mass index (BMI) and increasing prostate size and decreased with more recent year of RRP (all P<0.001). The mean-adjusted EBL in normal-weight men (BMI<25 kg/m(2)) was 807 ml compared to 1067 ml among severely obese men (BM I>or=35 kg/m(2)). Predicted EBL for men with the smallest prostates (<20 g) was 721 ml, compared to 1326 ml for men with prostates >or=100 g. Finally, statistically significant differences between centers were observed, with mean-adjusted EBL ranging from 844 to 1094 ml. Both BMI and prostate size are predictors of increased EBL. Prostate size is of particular note, as a nearly twofold increased EBL was seen from the smallest (<20 g) to the largest prostates (>or=100 g). Over time, average EBL significantly decreased. Finally, significant differences in EBL were observed between centers. Patients with multiple risk factors should be forewarned they are at increased risk for higher EBL, which may translate into a greater need for blood transfusion.

Transabdominal Preperitoneal Robotic Inguinal Hernia Repair

Inguinal hernias are commonly encountered at the time of radical retropubic prostatectomy. Concurrent inguinal hernia repair and prostatectomy is well described for the open and traditional laparoscopic approach. Robotic prostatectomy is the fastest growing treatment of prostate cancer. Concurrent robotic prostatectomy and robotic inguinal hernia repair has not been previously described. We recently performed such a procedure and describe our technique and impressions of this approach in this paper. The robotic surgical system allowed for the secure and efficient closure of the large transabdominal peritoneal flap following the preperitoneal placement of the mesh prosthesis. The robotic operating console provides the surgeon with a more comfortable, ergonomic position than is possible in a traditional laparoscopic approach. Robotic inguinal hernia repair is feasible immediately following robotic prostatectomy and may have certain advantages over alternative techniques.

Radical Retropubic Prostatectomy in Immunosuppressed Transplant Recipients

Surgical treatment of transplant recipients in whom prostate cancer subsequently develops has been reported only sporadically in the literature. We reviewed our experience with radical retropubic prostatectomy in patients with solid organ transplants. Using our prostatectomy registry we identified 17 patients who underwent radical retropubic prostatectomy between 1988 and 2005 following organ transplantation. Clinicopathological features and outcome data were reviewed. Kidney, liver and heart transplants were performed before radical retropubic prostatectomy in 9, 7 and 3 patients, respectively. Median age at transplant and time of radical retropubic prostatectomy was 51 (range 37 to 65) and 59 years (range 45 to 70), respectively. Median prostate specific antigen was 5.8 (range 2.6 to 12.9) and all patients had clinically localized disease. Ten patients had a pathological Gleason score of 6 while the remaining had Gleason scores 7 or greater. No patient had positive lymph nodes and only 2 patients had pT3a or greater disease. Early complications included wound infection in 2 (12%) patients along with hematoma and myocardial infarction in 1 (6%) patient each. Late complications included incontinence (1 or more pads per day) in 2 patients while no patient had a hernia, bladder neck contracture, venous thrombosis or lymphocele. With a median followup of 4.9 years, biochemical recurrence developed in 1 patient and no patient had systemic progression or death due to prostate cancer. To our knowledge we report the largest experience with radical retropubic prostatectomy in transplant recipients. Our results suggest that radical retropubic prostatectomy is feasible for immunosuppressed patients, yet concern for infection and wound healing remain important. Healthy transplant recipients with an increased prostate specific antigen should undergo a prostate biopsy.

Pathologic Outcome of Unilateral Low Risk Prostate Cancers on Multicore Prostate Biopsy after Radical Prostatectomy

Purpose: To investigate clinicopathologic characteristics of unilateral, low risk prostate cancers detected via multi (≥12)-core prostate biopsy. Materials and Methods: One hundred four patients who underwent radical retropubic prostatectomy (RRP) for unilateral, low risk prostate cancer (clinical stage ≤T2a, biopsy Gleason sum ≤6, PSA ≤10ng/ml, and ipsilateral positive cores ≤2) detected via multi (≥12)-core prostate biopsy were enrolled. In this retrospective study, we reviewed the patients’ preoperative and pathologic data to assess potential predictors of pT2c or greater disease at the time of RRP, as well as characteristics of such disease. Results: Of the 104 subjects, only 34 (32.7%) were pathologically-proven to have unilateral disease, while the others showed pathologically-bilateral or worse disease from analysis of the RRP specimens. Subjects pathologically found to have uniand bi-lateral disease showed no significant differences regarding age, prostate-specific antigen (PSA), free-to-total PSA ratio, prostate volume, clinical stage, number of positive cores, biopsy Gleason score, number of total biopsy sites, and highest percentage of tumor at any biopsy site. Multivariate logistic regression analysis revealed no significant preoperative predictors of pT2c or greater disease at RRP. Conclusions: Most patients with unilateral, low risk prostate cancer detected on multi (≥12)-core prostate biopsy actually had pathologicallyworse disease. For clinically-localized prostate cancer, a more accurate method to identify appropriate candidates for unilateral or focal ablative therapy should be developed. (Korean J Urol 2008;49:874-878) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Concurrent radical retropubic prostatectomy and Lichtenstein inguinal hernia repair through a single modified Pfannenstiel incision: a 3‐year experience

To present the results of a 3-year experience of radical retropubic prostatectomy (RRP) through a modified Pfannenstiel incision and concomitant repair of an inguinal hernia at the time of RRP, using a tension-free technique with a mesh, as described by Lichtenstein, with no additional incision(s), as 5-10% of patients with clinically localized prostate cancer have a detectable inguinal hernia. Patients who had RRP between October 2002 and July 2005 were included; we used a standard open RRP, in all cases using a modified Pfannenstiel incision. If the patient had an inguinal hernia, we approached the inguinal canal through the same incision and performed a Lichtenstein mesh repair, through the inguinal canal and avoiding placing mesh within the pelvis. Patients were followed at 1 and 6 weeks, 3-monthly for 1 year and 6-monthly thereafter. All clinical variables were entered into a database and analysed. In all, 450 men underwent RRP; 44 (10%) had inguinal hernia and in all, 56 hernias were repaired (32 unilateral and 12 bilateral; 16 indirect, 22 direct, six both) The mean (sd) age of the patients was 60 (7) years. Most patients were discharged within 36 h. The mean (sd) follow-up was 9 (8) months. Two patients had a superficial inguinal haematoma and one had a scrotal haematoma. They were treated conservatively with no sequelae. There were no wound infections. One patient developed a recurrent inguinal hernia. None had any clinical evidence of testicular atrophy or chronic pain. Concurrent formal mesh repair of the inguinal hernia and RRP through a single modified Pfannenstiel incision is safe and effective. The complications were minimal and recurrence rates were low. This procedure eliminates the risks involved with the preperitoneal mesh repair and avoids multiple incisions.

QUALITY OF LIFE FOLLOWING SIMULTANEOUS PLACEMENT OF PENILE PROSTHESIS WITH RADICAL PROSTATECTOMY

The present study examined erectile functioning, frequency of sexual contact, psychological functioning, partner/marital satisfaction and overall quality of life (QOL) after immediate sexual rehabilitation for prostate cancer via simultaneous placement of a penile prosthesis at radical retropubic prostatectomy (RP). Questionnaire packets were sent to and received from 51 men who had undergone simultaneous implantation of a penile prosthesis at the time of RP (PP+) and from a comparison group of 47 men who undergone RP alone (PP-) matched by age and year of surgery. Questionnaires included the Erectile Dysfunction Inventory of Treatment Satisfaction, the Depression Anxiety Stress Scales, the Dyadic Adjustment Scale and a prostate specific European Organization for the Research and Treatment of Cancer (EORTC) QOL questionnaire. Further comparisons were performed for a PP- subgroup consisting of 15 patients who had undergone nerve sparing RP. Higher Erectile Dysfunction Inventory of Treatment Satisfaction, EORTC Sexual Functioning, EORTC Total scores and more frequent sexual contact were reported by the PP+ group compared with the PP- group. The PP+ group also had better outcomes that approached but did not reach statistical significance compared with the nerve sparing subgroup with regard to Depression Anxiety Stress Scales and EORTC Emotional Functioning scores. Men who chose simultaneous placement of a penile prosthesis with RP reported greater overall QOL, erectile function and more frequent sexual contact than a comparison group of men who underwent RP alone. Placement of penile prosthesis at the time of RP may be a desirable option for men with prostate cancer in whom a nerve sparing procedure may not be ideal. These results underscore the importance of sexual function for men undergoing prostate cancer treatment.

Extended pelvic lymphadenectomy in men undergoing radical prostatectomy - an update on &gt; 300 cases

4612 Background: Lymph node dissection (LND) in PCA is considered as a mere staging procedure and limited to obturator and external iliac nodes. Since the prostate drains into the external iliac, hypogastric, lateral and subaortic sacral nodes, metastases might be missed by the standard approach. We performed a radical pelvic lymphadectomy (RLND) in pts with PCA to assess frequency and location of lymph node metastases and to evaluate the reliability of current prediction models for lymph node involvement. Methods: 311 pts underwent RLND at time of radical retropubic prostatectomy via an extraperitoneal approach. RLND comprised 8 selective fields: external, internal and common iliac nodes, obturator nodes bilaterally. Nodes from each location and side were submitted separately for pathohistologic evaluation. Pathohistology of lymph nodes was compared to serum PSA, preoperative clinical stage and biopsy Gleason sum, pathohistological stage and Gleason sum of the prostatectomy specimen. Reliability of Partin tables, CART analysis and clinical parameters in terms of accurate prediction of lymph nodes metastases was evaluated. Results: Lymph node metastases were diagnosed in 19.8%; mean number of dissected lymph nodes was 28 (21–42). 22% of lymph node metastases were located in the internal and common iliac region only. 23/58 pts had 1 positive lymph node, 18 pts had 2, 7 pts had 3 and 8 pts had > 3 lymph nodes involved. Preoperative PSA serum levels were 26.8 (3.5–133)ng/ml and 16.5 (2.5–125)ng/ml in pts with and without lymph node metastases, resp. (p<0.05). CART nomograms did not accurately predict lymph node metastases with 58% of pN+ having been understaged. 27% and 58% of pN+ pts had serum PSA levels <10ng/ml and a biopsy Gleason sum <7, resp. The Partin tables understaged 33.5% of pts with positive lymph nodes. Conclusions: 47% of pts demonstrate positive lymph nodes around the internal and common iliac artery making this area essential for adequate staging LND. Current clinical staging systems (Partin, CART) miss up to 50% of all pN+ pts. Radical pelvic lymphadenectomy represents the standard lymphadenectomy technique of choice in surgical management of PCA. No significant financial relationships to disclose.

Concurrent radical retropubic prostatectomy and inguinal hernia repair through a modified Pfannenstiel incision.

To describe a technique for concurrent radical retropubic prostatectomy (RRP) and inguinal hernioplasty, using a modified Pfannenstiel incision. RRP is usually done through a midline lower abdominal incision but some patients with localized prostate cancer have an inguinal hernia. Concurrent inguinal hernia repair at the time of RRP with the usual method is only possible by either a preperitoneal mesh repair or formal hernioplasty, requiring an additional incision(s). A 10-12 cm Pfannenstiel incision is made along the pubic hairline centred over the pubic symphysis, and a 'Y'-shaped incision in the rectus sheath. The rectus muscle is split vertically along the midline, followed by RRP. After removing the prostate and completing the anastomosis, the surgeon identifies the inguinal canal along the inferior and lateral aspect of the transverse incision and uses a formal tension-free hernioplasty with a 3 x 5 cm polypropylene mesh. We used this technique in fifteen concurrent inguinal hernioplasties (two bilateral hernias and thirteen unilateral) at the time of RRP, with no additional incisions, using the formal tension-free Lichtenstein technique. One patient with bilateral hernias had a right indirect inguinal hernia, and all the remaining men had a direct inguinal hernia. All patients were discharged 2 days after surgery, with no complications associated with the procedure and no recurrences; however, the follow-up was short (mean 5.5 months). A modified Pfannenstiel incision is ideal for concurrent RRP and inguinal hernioplasty, providing excellent exposure of the pelvic structures and allowing the surgeon to use a formal tension-free mesh hernioplasty through the same incision. Wound healing and cosmetic results are excellent.

Optimizing laboratory use of human vas deferens specimens for microsurgical practice

Objectives. To determine whether freezing harvested human vas deferens would preserve the tissue for later microsurgical practice. Learning and maintaining microsurgical skills requires laboratory practice. The proper preservation of the human vas deferens is important if harvested specimens are to be used for laboratory vasovasostomy. Methods. Segments of human vas deferens harvested at the time of radical retropubic prostatectomy were preserved at −20°C without media, in normal saline and in glycerol. At 2 weeks, the specimens were thawed and graded for freshness of appearance, mucosal preservation, mucosal suturing quality, muscularis preservation, and muscularis suturing quality at laboratory vasovasostomy (grade 1, poor; 2, fair; and 3, good). Mucosa and muscularis scores were calculated as the sum of the respective preservation and suturing quality grades. The preserved samples were compared with fresh human vas deferens specimens. Results. Freezing human vas deferens segments in normal saline or glycerol improved the mucosa and muscularis scores at 2 weeks compared with freezing tissues without media. However, a decrease in the freshness of appearance grade was noted. None of the freezing methods resulted in tissue quality as good as fresh vas deferens. Conclusions. Human vas deferens can be preserved for later microsurgical vasovasostomy practice at −20°C. Freezing in normal saline and glycerol improved the mucosa and muscularis scores compared with freezing without media, although a decrease in the freshness of appearance grade was noted. All three methods of freezing provided sufficient preservation for laboratory microsurgical vasovasostomy compared with fresh tissue.

Bilateral nerve grafting during radical retropubic prostatectomy: extended follow-up

Objectives. To confirm the benefit of using an interposition sural nerve graft at the time of radical retropubic prostatectomy in an extended series of men with at least 1 year of follow-up. We previously reported the return of erectile function after resection of both cavernous nerves. Methods. Twenty-eight potent men with clinically localized prostate cancer underwent radical retropubic prostatectomy with deliberate wide bilateral neurovascular bundle resection and the placement of bilateral nerve grafts. Erectile dysfunction questionnaires and patient interviews were completed at 6-month intervals. A minimum of 12 months of follow-up (mean 23 ± 10 months) was obtained for 23 men (mean age 58 ± 6 years). A control group of 12 men who underwent bilateral nerve resections, but declined nerve graft placement, was also followed up. Results. Of the 23 men, 6 (26%) had spontaneous, medically unassisted erections sufficient for sexual intercourse with vaginal penetration. An additional 6 men (26%) described “40% to 60%” spontaneous erections (fullness, no rigidity, not able to penetrate). Ten men (43%) had intercourse with sildenafil. No demonstrable erections occurred before 5 months postoperatively. The greatest return of function thus far was observed at 18 months after surgery. Conclusions. This surgical technique continues to show promise as an advance in prostate cancer surgery. The results of this study demonstrated recovery of erectile function in men who underwent bilateral nerve graft placement during radical retropubic prostatectomy when both cavernous nerves were deliberately resected.

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

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

Treatment outcome after radical prostatectomy is not adversely affected by a pre-existing penile prosthesis

Objectives. To report on the safety of radical retropubic prostatectomy (RRP) in patients with a penile prosthesis presenting with clinically localized prostate cancer. Methods. From January 1990 to December 1997, 8 consecutive men with a penile prosthesis underwent RRP for clinically localized prostate cancer. Retrospective data regarding patient population, operating time, estimated blood loss, length of hospital stay, and clinical outcome were evaluated. Results. Mean patient age was 65.4 years (range 57 to 70) at the time of RRP, with a mean preoperative serum prostate-specific antigen level of 11.5 ng/mL. Mean duration of RRP surgery was 183.9 minutes, and the mean estimated blood loss was 1281.8 mL. No complication requiring penile prosthesis removal occurred. In 1 case, the reservoir tubing was punctured during closure of the abdominal fascia wall. This was immediately recognized and fixed. All patients had a functioning penile prosthesis after RRP. Conclusions. RRP can be safely and expeditiously performed in patients with a pre-existing penile prosthesis. The risk of prosthesis malfunction after RRP is very low. Patients with a penile prosthesis and prostate cancer should not be denied the option of undergoing RRP.

Rectus Fascial Sling Suspension of the Vesicourethral Anastomosis After Radical Prostatectomy

A study was performed to ascertain if fascial sling suspension of the anastomosis after radical retropubic prostatectomy would enhance postoperative continence rates. A fascial sling suspension with a strip harvested from the fascia of the rectus muscle was performed at the time of radical retropubic prostatectomy in 30 patients (group 2). Postoperative continence was compared to that of 30 previous patients (group 1) operated on by the same surgeon. Complete continence rates (no protection needed at any time) were 18 of 30 men (60%) in group 2 and 10 of 30 (33%) in group 1 (p = 0.069) at 1 month, 28 of 30 men (93%) in group 2 and 21 of 30 (70%) in group 1 (p = 0.042) at 3 months, 30 of 30 in group 2 (100%) and 27 of 30 (90%) in group 1 at 6 months, and 30 of 30 in group 2 (100%) and 28 of 30 (93%) in group 1 at 9 and 12 months. Fascial sling suspension resulted in an earlier return and more complete recovery of urinary continence in men undergoing radical prostatectomy.

Rectus Urethromyoplasty of Radical Prostatectomy Anastomosis Decreases Postoperative Incontinence and Anastomotic Stricture; Technique and Preliminary Results

To investigate the effect of rectus urethromyoplasty on vesicourethral anastomosis healing during radical retropubic prostatectomy (RRP) and in an animal model. Three groups of 10 female rats were studied. After complete urethral transection, group A animals underwent a primary urethral anastomosis, while rectus urethromyoplasty was used to reinforce the anastomosis of the animals in group B. Group C animals served as controls. All animals underwent urodynamic evaluation one month postoperatively, then were sacrificed for histological analysis. In 3 clinical subjects at the time of RRP, a 2-3 cm x 6-8 cm. strip of rectus muscle was isolated with its blood supply intact, emanating from an inferior epigastric artery pedicle. This muscular band was used to encircle the vesico-urethral anastomosis, suspending it slightly but without tension, and securing it to the pubic symphysis. The micturition pattern, bladder capacity, and leak point pressure of the 3 groups of animals were not significantly different. Histological examination of the rectus sling revealed viable muscle with histofibroblast, collagen, and blood vessel ingrowth from the vascular rectus muscle into the urethra. Three successful clinical rectus urethromyoplasty cases were performed with over 12 months of follow-up. Reinforcement of the vesico-urethral anastomosis using rectus urethromyoplasty at the time of radical prostatectomy may improve continence by increasing urethral support and mucosal coaptation. This technique may decrease the incidence of stricture formation by augmenting blood supply available for healing of the anastomosis. Rectus urethromyoplasty may be especially beneficial to patients with an increased risk of requiring adjuvant radiation therapy post-prostatectomy.