Use Of Radical Prostatectomy Research Articles

Nationally representative trends and geographic variation in treatment of localized prostate cancer: the Urologic Diseases in America project.

IntroductionSeveral treatment options for clinically localized prostate cancer currently exist under established guidelines. We aim to assess nationally-representative trends in treatment over time and determine potential geographic variation using two large national claims registries.MethodsMen with prostate cancer insured by Medicare (1998–2006) or a private insurer (Ingenix database, 2002–2006) were identified using ICD-9 and CPT-4 codes. Geographic variation and trends in the type of treatment utilized over time were assessed. Geographic data was mapped using the GeoCommons online mapping platform. Predictors of any treatment were determined using a hierarchical generalized linear mixed model using the logit link function.ResultsThe use of radical prostatectomy (RP) increased, 33% to 48%, in the privately insured i3 database, while remaining stable at 12% in the Medicare population. There was a rapid uptake in the use of newer technologies over time in both the Medicare and i3 cohorts. The use of laparoscopic assisted prostatectomy increased from 1% in 2002 to 41% in 2006 in i3 patients, while the incidence increased from 3% in 2002 to 35% in 2006 for Medicare patients. The use of neoadjuvant/adjuvant androgen deprivation therapy (ADT) was lower in the i3 cohort and has decreased over time in both i3 and Medicare. Physician density had an impact on type of primary treatment received in the New England region, however, this trend was not seen in the Western or Southern regions of the United States.ConclusionUsing two large national claims registries, we have demonstrated trends over time and substantial geographic variation in the type of primary treatment used for localized prostate cancer. Specifically, there has been a large increase in the use of newer technologies, (i.e. laparoscopic-assisted prostatectomy and IMRT). These results elucidate the need for improved data collection on prostate cancer treatment outcomes to reduce unwarranted variation in care.

Increasing use of radical prostatectomy for lower-risk prostate cancer in Denmark.

149 Background: Denmark introduced radical prostatectomy (RP) as the last Nordic country in 1995. Since then, a rapid increment in the Danish incidence of prostate cancer (PCa) is indicative of increasing opportunistic prostate-specific antigen (PSA) testing. We hypothesized that an increasing proportion of men undergo RP for lower-risk PCa. Methods: All patients undergoing RP in Denmark between 1995 and 2011 were included. Changes over time in age at surgery, preoperative PSA, clinical T-category, biopsy Gleason score (GS) are described. Tests for statistically significant changes in trends were performed using linear regression and Cochran-Armitage trend test. Results: Median age at surgery increased from 61.4 to 64.8 (p<0.0001) during the 16 year period. Median preoperative PSA declined from 11.5 to 7.9 ng/ml (p<0.0001). Distribution of biopsy GS changed significantly, especially after 2005. Biopsy GS=7 was found in 20.2% of the patients in 2005 compared to 57.1% in 2011. The proportion of T1 disease increased from 32% to 56%. The proportion of patients above age 65 increased from 26.8% to 48.3% in the 16 year period studied. To adjust for grade, PSA, and age migration, we analyzed changes in the proportion of men age over age 65, with PSA less than or equal to 10 ng/ml, biopsy GS≤3+4, and clinical T1 disease over time. In the 16 year period, this proportion increased from 2% to 16% (p<0-001) of the cohort undergoing RP in Denmark. Conclusions: Significant preoperative age, stage, and Gleason grade migration was found in this complete Danish nation-wide cohort of patients undergoing RP during the past 16 years. This has occurred in the absence of any major changes to the national Danish guidelines for diagnosis and treatment of localized PCa. This effect is likely attributed to an increasing use of PSA although national guidelines recommend against PSA screening. Further, new guidelines from the International Society of Urological Pathology have had a major impact on risk classification. According to recently published randomized trials, the risk of overtreatment of localized PCa with RP is an increasing problem in Denmark.

Early Removal of Urethral Catheter with Suprapubic Tube Drainage Versus Urethral Catheter Drainage Alone after Robot-Assisted Laparoscopic Radical Prostatectomy

Retrospective single institution data suggest that postoperative pain after robot-assisted laparoscopic radical prostatectomy is decreased by early removal of the urethral catheter with suprapubic tube drainage. In a randomized patient population we determined whether suprapubic tube drainage with early urethral catheter removal would improve postoperative pain compared with urethral catheter drainage alone. Men with a body mass index of less than 40 kg/m(2) who had newly diagnosed prostate cancer and elected robot-assisted laparoscopic radical prostatectomy were included in analysis. Block randomization by surgeon was used and randomization assignment was done after completing the urethrovesical anastomosis. In patients assigned to suprapubic tube drainage the urethral catheter was removed on postoperative day 1 and all catheters were removed on postoperative day 7. Visual analog pain scale and satisfaction questionnaires were administered on postoperative days 0, 1 and 7. A total of 29 patients were randomized to the urethral catheter vs 29 to the suprapubic tube plus early urethral catheter removal at the time of interim futility analysis. Mean visual analog pain scale scores did not differ between the groups at any time point and a similar percent of patients cited the catheter as the greatest bother with nonsignificant differences in treatment related satisfaction. Complications during postoperative week 1 did not vary between the groups. Based on interim results the trial was terminated due to lack of effect. Patients randomized to suprapubic tube vs urethral catheter drainage for the week after prostatectomy had similar pain, catheter related bother and treatment related satisfaction in the perioperative period. We no longer routinely offer suprapubic tube drainage with early urethral catheter removal at our institution.

Patterns of care for men diagnosed with prostate cancer in Victoria from 2008 to 2011

To describe patterns of care for men diagnosed with prostate cancer in Victoria, Australia, between 2008and 2011. Men who were diagnosed with prostate cancer at 11public and six private hospitals in Victoria from August 2008to February 2011, and for whom prostate cancer notifications were received by the Prostate Cancer Registry. Characteristics of men diagnosed with prostate cancer; details of treatment provided within 12months of diagnosis, according to National Comprehensive Cancer Network risk categories; and characteristics of men who did not receive active treatment within 12months of diagnosis. Treatment details were collected for 98.1% of men who were assessed as eligible to participate in the study (2724/2776) and were confirmed by telephone 12months after diagnosis for 74.4% of them (2027/2724). Most patients (2531/2724[92.9%]) were diagnosed with clinically localised disease, of whom 1201(47.5%) were at intermediate risk of disease progression. Within 12months of diagnosis, 299of the 736patients (40.6%) who had been diagnosed as having disease that was at low risk of progression had received no active treatment, and 72of 594patients (12.1%) who had been diagnosed as having disease that was at high risk of progression had received no active treatment. Of those diagnosed as having intermediate risk of disease progression, 54.5% (655/1201) had undergone radical prostatectomy. Those who received no active treatment were more likely than those who received active treatment to be older (odds ratio [95% CI], 2.96[2.01-4.38], 10.94[6.96-17.21] and 32.76[15.84-67.89], respectively, for age 65-742013s, 75-842013s and ≥852013s, compared with <552013s), to have less advanced disease (odds ratio [95% CI], 0.20[0.16-0.26], 0.09[0.06-0.12] and 0.05[0.02-0.90], respectively, for intermediate, high and very high-risk [locally advanced] or metastatic disease, compared with low-risk disease) and to have had their prostate cancer notified by a private hospital (odds ratio [95% CI], 1.35[1.10-1.66], compared with public hospital). Our data reveal a considerable "stage migration" towards earlier diagnosis of prostate cancer in Victoria and a large increase in the use of radical prostatectomy among men with clinically localised disease.

235 RADICAL PROSTATECTOMY BECAME INCREASINGLY POPULAR FOR INTERMEDIATE-TO-HIGH RISK PROSTATE CANCER OVER THE LAST DECADE IN THE UNITED STATES

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History (I)1 Apr 2013235 RADICAL PROSTATECTOMY BECAME INCREASINGLY POPULAR FOR INTERMEDIATE-TO-HIGH RISK PROSTATE CANCER OVER THE LAST DECADE IN THE UNITED STATES Matthew Maurice and Hui Zhu Matthew MauriceMatthew Maurice Cleveland, OH More articles by this author and Hui ZhuHui Zhu Cleveland, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1615AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We examined the use of radical prostatectomy (RP) as the primary treatment for prostate cancer in the United States (US), especially since the introduction of the da Vinci® Surgical System in 2004. METHODS The National Cancer Database (NCDB) captures about 70% of all newly diagnosed cancer cases in the US. We queried the NCDB from 2000-2009 for prostate cancers initially managed with “surgery only”. Specifically, we examined the trend of RP usage by cancer-risk group, age group, and practice setting. RESULTS RP usage steadily increased (35.2% to 49.7%) from 2000-2009, especially after 2004, when its usage increased at a rate 1.9x that seen in the previous 4 years (Figure 1). This trend was present across all age groups but was unique to cancer stage 2 and 3 groups (Figure 2). A similar trend was noted across hospital types with the exception of the Veterans Affairs (VA) medical system where RP usage remained stable (Figure 3). In teaching hospitals and comprehensive cancer centers, the increase in RP usage occurred rapidly, at a rate 1.3-1.6x that seen in community hospitals. Teaching hospitals led this trend by 1-2 years. CONCLUSIONS Last decade, the use of RP as the primary treatment for prostate cancer increased across most age and cancer-risk groups and has become the predominant treatment option for intermediate-to-high-risk disease. This increase coincided with the adoption of robotic technology and was not noted in a hospital system with more limited robotic adoption. This suggests that the trend has been driven mainly by the adoption of new technology rather than by clinical indications. Further studies are needed to justify the widespread adoption of RP, especially in high-risk patients. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e96-e97 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Maurice Cleveland, OH More articles by this author Hui Zhu Cleveland, OH More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Increasing Use of Radical Prostatectomy for Nonlethal Prostate Cancer in Sweden

The number of patients in Sweden treated with radical prostatectomy for localized prostate cancer has increased exponentially. The extent to which this increase reflects treatment of nonlethal disease detected through prostate-specific antigen (PSA) screening is unknown. We undertook a nationwide study of all 18,837 patients with prostate cancer treated with radical prostatectomy in Sweden from 1988 to 2008 with complete follow-up through 2009. We compared cumulative incidence curves, fit Cox regression and cure models, and conducted a simulation study to determine changes in treatment of nonlethal cancer, in cancer-specific survival over time, and effect of lead-time due to PSA screening. The annual number of radical prostatectomies increased 25-fold during the study period. The 5-year cancer-specific mortality rate decreased from 3.9% [95% confidence interval (CI), 2.5-5.3] among patients diagnosed between 1988 and 1992 to 0.7% (95% CI, 0.4-1.1) among those diagnosed between 1998 and 2002 (P(trend) < 0.001). According to the cure model, the risk of not being cured declined by 13% (95% CI, 12%-14%) with each calendar year. The simulation study indicated that only about half of the improvement in disease-specific survival could be accounted for by lead-time. Patients overdiagnosed with nonlethal prostate cancer appear to account for a substantial and growing part of the dramatic increase in radical prostatectomies in Sweden, but increasing survival rates are likely also due to true reductions in the risk of disease-specific death over time. Because the magnitude of harm and costs due to overtreatment can be considerable, identification of men who likely benefit from radical prostatectomy is urgently needed.

Reply

Male stress urinary incontinence presents a challenge to any urologist because it occurs as a result of differing surgical procedures, varying degrees of severity, and varying degrees of patient expectation. Therefore, we wished to study our own data in an attempt to identify risk factors for failure of male slings. Editorial CommentUrologyVol. 78Issue 1PreviewThis paper deals with a subject that offers great technical challenges to every urologist. The incontinent male is almost always a very unhappy fellow. Resolution of incontinence, regardless of cause, but especially in an era of widespread use of radical prostatectomy, is a key element to the achievement of patient perception of a successful outcome. Full-Text PDF

Is radical prostatectomy a viable therapeutic option in clinically locally advanced (cT3) prostate cancer?

According to the literature, the current preferred treatment for T3 prostate cancer is a combination of radiotherapy and extended hormone therapy. The preoperative staging based on digital rectal examination results alone now appears obsolete from the investigated series, in which 20% of T3 prostate cancer is over-staged during physical examination. Prostatic magnetic resonance imaging is becoming increasingly necessary to evaluate extraprostatic extension during the preoperative evaluation. European Association of Urology guidelines recommend the use of radical prostatectomy only in selected patients with cT3a who have a PSA <20 ng/mL and a biopsy Gleason score ≤8. The cancer control obtained after the implementation of radical prostatectomy is variable from one series to another, with PSA-free survival rates at 5, 10 and 15 years ranging from 45 to 62%, 43 to 51% and 15 to 49%, respectively. The specific survival rates at 5, 10 and 15 years are between 84 and 98%, 84 and 91% and 76 and 84%, respectively. The surgical margins rate varies from 22% to 61% depending on the specific operative technique used and the surgeon's own experience level. Regarding urinary continence, functional outcomes are in line with those of prostatectomy for localized prostate cancer. Upon consideration of erectile dysfunction, the rates are linked with the type of surgery performed, which can at times be fairly extensive. There is no impact on the overall or specific survival rate of neoadjuvant treatments. One of the problems currently depends on the efficacy of early adjuvant treatment after prostatectomy, especially regarding the use of adjuvant external beam radiotherapy. Radical prostatectomy can be considered in selected cases as a viable alternative to the first-line treatment option. However, patients must be counselled that they may undergo complementary treatments during the postoperative course of the disease.

Risk Profiles and Treatment Patterns Among Men Diagnosed as Having Prostate Cancer and a Prostate-Specific Antigen Level Below 4.0 ng/mL

Despite controversy over the benefit of prostate-specific antigen (PSA) screening, little is known about risk profiles and treatment patterns in men diagnosed as having prostate cancer who have a PSA value less than or equal to 4.0 ng/mL. We used data from the Surveillance, Epidemiology, and End Results system to describe patient characteristics and treatment patterns in the cases of 123 934 men with newly diagnosed prostate cancer from 2004 to 2006. Age-standardized treatment rates were calculated in 5-year age strata. Logistic regression was used to quantify the odds ratios (ORs) of men with low- and high-risk disease and the use of radical prostatectomy (RP) or radiation therapy (RT). Men with a PSA level of 4.0 ng/mL or lower represent 14% of incident prostate cancer cases. Fifty-four percent of men diagnosed as having prostate cancer and PSA levels lower than 4.0 ng/mL harbor low-risk disease (stage, < or =T2a, PSA level, < or =10 ng/mL, and Gleason score, < or =6), but over 75% of them received RP or RT. Men with screen-detected prostate cancer and PSA values lower than 4 ng/mL were 1.49 (95% confidence interval [CI], 1.38-1.62) and 1.39 (95% CI, 1.30-1.49) times more likely to receive RP and RT, respectively, and were less likely to have high-grade disease than men who had non-screen-detected prostate cancer (OR, 0.67; 95% CI, 0.60-0.76). Most men diagnosed as having prostate cancer with a PSA threshold below 4.0 ng/mL had low-risk disease but underwent aggressive local therapy. Lowering the biopsy threshold but retaining our inability to distinguish indolent from aggressive cancers might increase the risk of overdiagnosis and overtreatment.

Patterns of Care for Radical Prostatectomy in the United States From 2003 to 2005

The demand for minimally invasive radical prostatectomy is increasing, although population based outcomes remain unclear. We assessed use and outcomes in American men undergoing radical prostatectomy. We identified 14,727 men undergoing minimally invasive, perineal and retropubic radical prostatectomy during 2003 to 2005 using nationally representative, employer based administrative data. We assessed the association between surgical approach and outcomes, adjusting for age, race, comorbidity and geographic region. Minimally invasive radical prostatectomy use increased from 5.4% to 24.4%, while conversion to open surgery decreased from 28.6% to 4.5% in the 3-year study. Men undergoing minimally invasive and perineal radical prostatectomy vs retropubic radical prostatectomy experienced fewer 30-day complications (14.2% and 14.9% vs 17.5%, p = 0.001), blood transfusions (2.2% and 3.6% vs 9.1%, p <0.001) and anastomotic strictures (6.8% and 8.5% vs 12.9%, p <0.001), and shorter median length of stay (1 and 2 days, respectively, vs 4, p <0.001). On adjusted analysis minimally invasive vs retropubic radical prostatectomy was associated with fewer 30-day complications (OR 0.78, 95% CI 0.66, 0.92), transfusions (OR 0.24, 95% CI 0.16, 0.34) and anastomotic strictures (OR 0.50, 95% CI 0.40, 0.62), and shorter length of stay (parameter estimate -0.53, 95% CI -0.58, -0.49). Similarly perineal vs retropubic radical prostatectomy was associated with fewer transfusions (OR 0.50, 95% CI 0.31, 0.82) and anastomotic strictures (OR 0.65, 95% CI 0.47, 0.90), and shorter length of stay (parameter estimate -0.53, 95% CI -0.42, -0.29). While the use of minimally invasive radical prostatectomy surged, men undergoing minimally invasive vs perineal radical prostatectomy experienced a lower risk of 30-day complications, blood transfusions and anastomotic strictures, and a shorter length of stay. Furthermore, perineal vs retropubic radical prostatectomy was also associated with relatively favorable outcomes. Further study is needed to assess continence, potency and cancer control.

The impact of a single disease site treatment facility on prostate cancer care in a community-hospital based radiation oncology practice

6626 Background: The purpose of this study was to evaluate the pattern of care in a community-hospital based radiation oncology practice after the opening of a referring physician-owned single disease-site specific radiation oncology facility. Methods: Hospital data for radical prostatectomy, prostate seed implants, intensity modulated radiation therapy (IMRT) treatments, and radiation oncology department profit/loss were used to evaluate changes in the pattern of care for patients with prostate cancer at a community hospital located in Central Pennsylvania (PA) between 2003 and 2007. Commonwealth of PA public claims data were used to determine the frequency of radical prostatectomy at community-hospitals in the primary service area (PSA). Comparisons of the variables of interest were made to 2003. A free- standing radiation oncology center devoted to prostate cancer care located near the community hospital was opened in 7/06. Results: Table 1 depicts the percent change when compared to 2003 of the variables of interest by fiscal year. A negative number signifies a decrease when compared to 2003 and a positive number reflects an increase when compared to 2003. Commonwealth of PA data for radical prostatectomy for 2 community hospitals in the community hospital's PSA show a similar trend for a decrease in the use of radical prostatectomy. Conclusions: Absent any clinical data that would suggest a shift in outcomes, community practice appears to have changed with the opening of a referring physician owned free-standing radiation oncology facility devoted to prostate cancer care with a 22% and 80% decrease in prostate seed implants compared to prior to the center opening. The trend towards a reduction in the use of radical prostatectomy remained unchanged. Informed consent of all treatment options for patients with prostate cancer in this market has to be questioned with the dramatic reduction in the number of prostate seed implants. Radical Prostatectomy Prostate Seed Implant IMRT Treatments Radiation Oncology Department Profits 2004 -24% 8% 177% 126% 2005 -9% 1% 196% 129% 2006 -14% -22% 147% 59% 2007 -36% -80% -17% -50% No significant financial relationships to disclose.

Secular trends in prostate cancer mortality, incidence and treatment: England and Wales, 1975–2004

To aid the interpretation of the trends in prostate cancer mortality, which declined in the UK in the early 1990 s for unknown reasons, by investigating prostate cancer death rates, incidence and treatments in England and Wales in 1975-2004. Join-point regression was used to assess secular trends in mortality and incidence (source: Office of National Statistics), radical prostatectomy and orchidectomy (source: Hospital Episode Statistics database) and androgen-suppression drugs (source: Intercontinental Medical Statistics). Prostate cancer mortality declined from 1992 (95% confidence interval, CI, 1990-94). The relative decline in mortality to 2004 was greater and more sustained amongst men aged 55-74 years (annual percentage mortality reduction 2.75%; 95% CI 2.33-3.18%) than amongst those aged >or=75 years (0.71%, 0.26-1.15%). The use of radical prostatectomy increased between 1991 (89 operations) and 2004 (2788) amongst men aged 55-74 years. The prescribing of androgen suppression increased between 1987 (33,000 prescriptions) and 2004 (470,000). The decrease in prostate cancer mortality was greater amongst men aged 55-74 years than in those aged >or=75 years, but pre-dated the substantial use of prostate-specific antigen screening and radical prostatectomy in the UK. An increase in radical therapy amongst younger groups with localized cancers and screen-detected low-volume locally advanced disease as a result of stage migration, as well as prolonged survival from increased medical androgen suppression therapy, might partly explain recent trends.

Trends and predictors of aggressive therapy for clinical locally advanced prostate carcinoma

To determine the patterns and predictors of aggressive local therapies for patients with clinically advanced (cT3) prostate carcinoma, as the USA National Cancer Institute considers external beam radiotherapy (EBRT) to be the most appropriate treatment for these patients, and currently there is less evidence supporting the use of radical prostatectomy (RP). We used the Surveillance, Epidemiology and End Results (SEER) cancer registries to identify patients diagnosed with cT3 disease between 1995 and 2001. Sociodemographic and clinical data included patient age, race/ethnicity, marital status, SEER registry, year of diagnosis, tumour stage and grade, and treatment. Multivariate logistic regression was used to identify significant predictors of receiving (i) RP vs EBRT, (ii) any aggressive local treatment (RP or EBRT) or no treatment. Between 1995 and 2001, the proportion of men receiving aggressive local therapy for cT3 disease increased by 11% (58.4% to 69.4%), with a 20% increase in EBRT (40.3% to 60.2%) but a decline by half in RP (18.1% to 9.3%). Younger age was the strongest predictor of receiving RP rather than EBRT, and younger age with being married being a predictor of receiving aggressive local therapy (adjusted relative risk for marriage 1.33, 95% confidence interval 1.18-1.87). Black men were significantly less likely than non-Hispanic white men to receive aggressive therapy, with a relative risk of 0.56 (0.45-0.69). By 2001, 70% of patients with cT3 disease were receiving aggressive local therapy, with EBRT 6.5 times more common than RP. Clinical trials are needed to rigorously assess the effects of different local treatment strategies on clinical outcomes in men with cT3 prostate carcinoma.

Trends in Prostate Cancer Incidence, Hospital Utilization and Surgical Procedures, Canada, 1981–2000

Numbers of new prostate cancer cases in Canada continue to increase because of increasing prostate cancer incidence, population growth, aging of the population, and earlier detection methods such as PSA (prostate-specific antigen) testing. Concern has been expressed that PSA-related increases in incidence will make unaffordable demands on Canadian hospital resources. Our objective is to relate increases in prostate cancer incidence to trends in hospitalizations and in- patient treatment. Hospitalizations with prostate cancer as primary diagnosis were obtained from the Hospital Morbidity Database, estimates of prostate cancer day surgery from the Discharge Abstract Database, newly diagnosed cases from the Canadian Cancer Registry, and prostate cancer deaths from the Vital Statistics Mortality Databases--all for the years 1981-2000. Between 1981-2000, the number of new cases rose from 7,000 to 18,500 with a transient peak, 1991-1994. Hospitalizations rose parallel to the incidence until 1991 but then fell sharply in spite of further increasing incidence. The use of radical prostatectomy (RP) increased steadily, but transurethral prostatectomy and bilateral orchiectomy decreased in the 1990s. Decreases in length of stay and in number of hospitalizations resulted in considerably decreased annual hospital days for all prostate cancer in-patient procedures except RP, which remained level since 1993. A net decrease in number of in-patient days occurred, despite the increasing number of new prostate cancer cases and the increasing use of radical prostatectomy. We concluded that increases in hospital utilization due to early detection programs, such as PSA testing, are unlikely to overwhelm in-patient services of Canadian hospitals.

Impact of brachytherapy on regional, racial, marital status, and age‐related patterns of definitive treatment for clinically localized prostate carcinoma

The impact of the increased use of permanent prostate brachytherapy compared with other treatment modalities (such as radical prostatectomy and external-beam radiation therapy [EBRT]) for the treatment of clinically localized prostate carcinoma, and the previously reported regional, racial, and age-related variations in prostate carcinoma treatment, have not been well characterized to date. Therefore, the authors evaluated the impact of permanent prostate brachytherapy on the relative rates of the use of specific prostate carcinoma treatment modalities over time. Surveillance, Epidemiology, and End Results (SEER) cancer registry data from 1995 to 2000 were analyzed in a longitudinal, observational study utilizing bivariate and multivariate techniques. Differential changes in the use of specific definitive treatment modalities were noted by region, age group, racial/ethnic group, and marital status. Increasing use of permanent prostate brachytherapy, with and without concomitant EBRT, was proportional to the decreasing use of radical prostatectomy alone and EBRT alone over time. The current study revealed that permanent prostate brachytherapy appears to be replacing other treatment modalities in increasing numbers of clinically localized prostate carcinoma cases. Persistent regional, racial/ethnic, marital status, and age-related differences in the use of permanent prostate brachytherapy merit further investigation.

Use of acute normovolemic hemodilution in patients undergoing radical prostatectomy

Objectives To evaluate the efficacy and safety of acute normovolemic hemodilution (ANH) in patients undergoing radical prostatectomy. Preoperative autologous blood donation (PAD) is widely accepted as a means of reducing the need for allogeneic blood transfusion in radical prostatectomy. ANH is an alternative method for obtaining autologous blood. Methods On the basis of our previous report that showed the equivalence of PAD and ANH, we prospectively replaced PAD with ANH as a standard practice for radical prostatectomy after September 1999. Of 174 radical prostatectomy patients between September 1999 and June 2004, 153 underwent ANH alone, 15 chose to receive both PAD and ANH, and ANH was contraindicated in 15 because of comorbidities. Results For the 153 patients undergoing ANH alone, 1032 ± 201 mL of autologous blood was collected. With an intraoperative blood loss of 1602 ± 926 mL, 14 patients (9.2%) received allogeneic blood transfusion. The preoperative, intraoperative nadir, and postoperative hematocrit value was 43.6% ± 3.4%, 25.8% ± 3.8%, and 31.9% ± 4.3%, respectively. No patient experienced a perioperative adverse event related to hemodilution or blood transfusion. Conclusions Our continued experience has shown that ANH is a safe and effective means of autologous blood procurement. Given its advantages, including lower cost, lower risk, and simplicity, we conclude that ANH can replace conventional PAD for use in radical prostatectomy, although the true value of ANH should be determined by future randomized studies including a no-treatment control group.

TREATMENT OF PATIENTS WITH HIGH RISK LOCALIZED PROSTATE CANCER: RESULTS FROM CANCER OF THE PROSTATE STRATEGIC UROLOGICAL RESEARCH ENDEAVOR (CaPSURE)

Pretreatment risk assessment models facilitate more appropriate selection of treatment for prostate cancer. However, men with high risk disease remain a challenge with significant potential for primary treatment failure. We characterize patterns of treatment for high risk prostate cancer in a community based cohort. In the Cancer of the Prostate Strategic Urological Research Endeavor (CaPSURE) database, a longitudinal disease registry of men with prostate cancer, we identified those with nonmetastatic, high risk disease based on T stage, tumor grade and serum prostate specific antigen (PSA). Differences in primary treatment, and the use of neoadjuvant and adjuvant therapy in patients at low, intermediate and high risk were assessed. In the high risk cohort predictors of the type of primary treatment, and the use of neoadjuvant and adjuvant androgen therapy were identified. Of the cancers 34%, 40% and 26% were low, intermediate and high risk, respectively. Differences in primary treatment type among the 3 risk groups were statistically significant (p <0.0001) with increasing external beam radiation therapy and androgen deprivation, and decreased surgery, brachytherapy and surveillance in men with high risk cancers. In this group older age, higher PSA and nonprivate insurance were associated with decreased use of radical prostatectomy. More than half of the men at high risk receiving radiation therapy also received androgen deprivation, which was significantly higher than in the low and intermediate risk groups (p <0.0001). Factors associated with androgen deprivation in high risk disease were primary therapy, PSA, Gleason sum, T stage, body mass index, insurance status and ethnicity. PSA and Gleason sum were the primary determinants of adjuvant radiation after prostatectomy. Men with high risk but nonmetastatic prostate cancer are more likely to receive radiation therapy as well as androgen deprivation with the latter as primary therapy or in conjunction with local treatment. These data stress the importance of pretreatment risk stratification, education regarding appropriate combinations of local and systemic therapies, and the consideration of novel clinical trials in patients at higher risk.

Die operative Therapie des lokalisierten Prostatakarzinoms

Surgical Treatment of Localized Prostate Cancer Objective: Discussed is the clinical use of radical prostatectomy in patients with clinically localized prostate cancer regarding outcome, quality of life, and morbidity based on own data and results of the literature. Methods: A review of the currently available literature was performed. Moreover, data of 1755 patients who underwent radical retropubic prostatectomy between 1992 and 2001 at our institution were analyzed in uni- and multivariate analyses and included. Results: 5-year disease-specific survival of about 80% is reported. Pathologic stage and the Gleason score are the most influencing factors on postoperative outcome. Continence rates of about 90% are common; nerve-sparing radical prostatectomy seemed to have a protecting factor on continence. Rates of erection depend on the extent of nerve sparing and achieve up to 90% after bilateral nerve sparing. 30-day perioperative morbidity decreased to less than 5% in mayor series with a mortality rate of nil. Conclusions: Selecting the right patient with clinically localized disease, radical prostatectomy showed excellent data on long-term follow-up. Due to respectful understanding of anatomical structures and improvements in surgical techniques, morbidity of the operation decreased and with the nerve-sparing technique quality of life increased.

Treatment of Prostate Cancer—The Clinical Use of Radical Prostatectomy

Objective: To discuss the clinical use of radical prostatectomy in patients with clinically localized prostate cancer regarding outcome, quality of life, and morbidity based on own data and results of the literature. Methods: A review of the currently available literature was performed. Moreover, data of 1755 patients who underwent radical retropubic prostatectomy between 1992 and 2001 at our institution were analyzed in uni- and multivariate analyses and included. Results: Disease-free survival of about 80% over a 5-year period are reported. Pathologic stage and the Gleason score are the most influencing factors on postoperative outcome. Continence rates of about 90% are common; nerve-sparing radical prostatectomy seemed to have a protecting factor on continence. Rates of erection depend on the extent of nerve-sparing and achieve up to 90% after bilateral nerve-sparing. 30-days perioperative morbidity decreased to less than 5% in major series with a mortality rate of nil. Conclusions: Selecting the right patient with clinically localized disease, radical prostatectomy showed excellent data on long-term follow-up. Due to respectful understanding of anatomical structures and improvements in surgical techniques, morbidity of the operation decreased and with the nerve-sparing technique quality of life increased.

Recent trends in the use of radical prostatectomy in England: the epidemiology of diffusion.

To describe recent trends in the use of radical prostatectomy (RP) in England, as there is currently no consensus on the most effective treatment for localized prostate cancer, although RP is the treatment of choice among urological surgeons for men aged < 70 years. Routine data were assessed to establish the number of RPs performed in England in 1991-99. Age-standardized operation rates were compared by region and socio-economic group, and the geographical spread of use mapped. The number of RPs performed annually increased nearly 20-fold between 1991 and 1999. Rates of surgery were greatest in the London National Health Service (NHS) regions and lowest in the Trent region. Outside London, the risk of surgery in a NHS hospital was significantly greater for men living in the least deprived areas; in London this trend was reversed. Rapid increases in the use of RP showed marked regional variations, most likely related to access to prostate-specific antigen testing and the location of surgeons able to carry out radical surgery. By 1999, a third of procedures were still being undertaken in 'low-volume' hospitals, with implications for the quality of care and outcomes. Crucially, these developments occurred in the absence of robust information about the effectiveness of RP. Recent funding of a randomized trial of treatment options in this area is welcome, but wider questions remain about the timing of the evaluation of surgical technologies.