Role of surgeon volume in radical prostatectomy outcomes.

PURPOSE: To examine the effect of hospital and surgeon volume on postoperative outcomes and to determine whether hospital or surgeon volume is the stronger predictor. PATIENTS AND METHODS: Using 1997 to 1998 claims data from a national 5% random sample of Medicare beneficiaries, we identified 2,292 men who underwent radical prostatectomy at 1,210 hospitals by 1,788 surgeons. Hospitals were classified as high (> or = 60 per year) or low (< 60 per year) volume according to radical prostatectomy experience over the 2-year period. Surgeons were classified as high (> or = 40 per year) or low (< 40 per year) volume. Multivariate logistic regression was performed to control for patient demographics and comorbidities when assessing the association of hospital and surgeon volume with in-hospital complications, length of stay, and anastomotic stricture rates. In-hospital complications included cardiac, respiratory, vascular, wound, genitourinary, and miscellaneous surgical and medical conditions. RESULTS: High-volume surgeons had half the complication risk (odds ratio [OR] = 0.53; 95% confidence interval [CI], 0.32 to 0.89) and shorter lengths of stay (4.1 v 5.2 days, P =.03) compared with low-volume surgeons. High-volume hospital patients tended to have fewer anastomotic strictures (OR = 0.72; 95% CI, 0.49 to 1.04). Patient age (> or = 75 years) was associated with more complications (OR = 1.9; 95% CI, 1.39 to 2.70), more anastomotic strictures (OR = 2.2; 95% CI, 1.54 to 3.15), and longer hospital stays (parameter estimate = 2.26; 95% CI, 1.75 to 2.77). CONCLUSION: Surgeon volume is inversely related to in-hospital complications and length of stay in men undergoing radical prostatectomy. Hospital volume is not significantly associated with outcomes after adjusting for physician volume. Further study is necessary to elucidate the mechanism of the volume-outcome effect.     

Long-term outcomes after radical prostatectomy performed in a community-based health maintenance organization

BACKGROUND: Radical prostatectomy is used widely for the treatment of patients with localized prostate carcinoma. No long-term analysis has been reported on a series of radical prostatectomies performed in a community-based health maintenance organization. METHODS: Charts and histologic slides were reviewed from 750 patients who underwent radical prostatectomy between 1970 and 1996 at a community-based health maintenance organization. The influences of a number of variables were analyzed for their impact on progression free survival (PFS) and overall survival (OS). RESULTS: With a median follow-up of 6.2 years among survivors, 137 patients (18%) had progressive disease, and 149 patients (20%) died from all causes. The median OS from the date of diagnosis was 15.7 years (95% confidence interval, 13.6-17.2), similar to the expected median survival of 16.2 years. The median PFS from diagnosis was not reached, but 75% of patients were progression free > or = 10.6 years after undergoing prostatectomy. The prognostic factors included Gleason score, age at diagnosis, and T stage. Outcomes were comparable with reports of surgical series from university-based practices. CONCLUSIONS: The patient characteristics that had important, favorable correlation with survival included Gleason score < or = 6, T1 or T2 tumor status, and younger age at diagnosis. Lower prostate-specific antigen values at diagnosis, together with the former two parameters, also had a favorable correlation with PFS. Radical prostatectomy in a community-based health maintenance organization was followed by long-term PFS and OS comparable to outcomes reported from university-based practices. The impact of radical prostatectomy on survival remains to be demonstrated.     

Pathological outcomes of Japanese men eligible for active surveillance after radical prostatectomy

Background

The aim of this study was to analyze the pathological features of prostatectomy specimens from patients with low-risk prostate cancer eligible for active surveillance (AS) and evaluate preoperative data suitable for predicting upstaged (≥pT3) or upgraded disease (Gleason score of ≥7), defined as ‘reclassification’.

Methods

A retrospective analysis of 521 consecutive radical prostatectomy procedures (January 2005 through to December 2011) performed at our institution without neoadjuvant hormonal therapy was performed. Eighty-four patients fulfilled the following criteria—clinical T1 or T2 disease, prostate-specific antigen (PSA) level of ≤10 ng/ml, one or two positive biopsies, and Gleason score of <7. Clinicopathological features at diagnosis were compared between patients with and without reclassification after radical prostatectomy.

Results

Forty of 84 patients (47.6 %) had a Gleason score of ≥7, and 8 (9.5 %) had upstaged disease (≥pT3). Seven patients with upstaged disease also showed upgraded reclassification. Two patients with reclassification showed biochemical recurrence at 59 and 89 months after surgery, respectively. Preoperative parameters evaluated included age, PSA level, PSA density (PSAD), clinical T stage, and number and percentage of positive prostate cores. Among 82 patients with complete data, univariate analysis showed that PSAD (ng/ml²) was a significant parameter to discriminate patients with reclassified disease and those without reclassified disease (p < 0.001). Multivariate analysis revealed that PSAD was the only independent variable to predict disease with reclassification (p = 0.006).

Conclusions

Preoperative PSAD may be a good indicator for selecting patients eligible for AS in the Japanese population.     

Urinary incontinence after radical prostatectomy

Despite improvements in knowledge and technique, a growing number of patients experience incontinence after radical prostatectomy. This may be the result of damage to sphincteric structures, bladder dysfunction, an obstructive stricture, or some combination of these. After an appropriate interval to allow for improvement, the patient should undergo a thorough evaluation to assess the contribution of the various causes and should then be managed using a sequential treatment approach. Following restoration of adequate emptying, bladder dysfunction should be controlled first, if present, and persistent stress incontinence should then be managed according to its severity. Many patients with significant persistent incontinence after radical prostatectomy will need to consider placement of an artificial urinary sphincter.     

Adjuvant radiotherapy after radical prostatectomy

Background:Within 5 years following radical prostatectomy, between 15 and 60% of patients with pT3 prostate carcinomas show an increasing prostate specific antigen (PSA)as a sign of local and/or systemic tumour progression. Adjuvant radiotherapy (RT)for positive margins (R1)aims to reduce residual tumour cells in the prostatic bed, thus possibly reducing the biochemical progression rate. Apart from a large number of retrospective investigations, available results are presented from three randomised studies which have either been published completely (or in abstract form).Results:For pT3 prostate carcinomas, agreeing data are presented from three randomised studies, which show around a 20% reduced biochemical progression rate (bNED)after 4 to 5 years. With these data the results of numerous retrospective studies were conformed. The majority of the authors used total doses of 60 Gy. From one randomised study an increased local control rate was demonstrated as basis for the extended freedom of biochemical progression. The rate of acute and late side effects after three dimensional (3-D)planned radiotherapy with 60 Gy is very small and the rate of severe side effects is below 2%. The data situation for pT2 prostate carcinomas with positive margins is worse. Here, controversial data are presented, which require further investigation. Only retrospective data demonstrated a 25% advantage for adjuvant RT. Therefore, adjuvant radiotherapy also seems reasonable for pT-2 carcinomas with positive margins.Conclusions:The effectiveness of adjuvant radiotherapy for patients with pT-3 tumours with positive margins with and without undetectable PSA levels with 60 Gy total dose has been demonstrated. A survival advantage has not been shown until now. 3-D treatment planning remains the standard technique for these patients.For patients with positive margins in organ-limited prostate carcinomas (pT2 R 1)randomised studies are recommended.It remains unclear whether the adjuvant RT is superior to the radiotherapy for rising PSA levels out of the undetectable range after radical prostatectomy.     

Erectile function after radical prostatectomy

The early detection of prostate cancer through the use of prostate-specific antigen screening has resulted in the performance of many more radical prostatectomy procedures as a curative treatment for this disease. Many patients who are candidates for this procedure already suffer from erectile dysfunction, and the incidence of inadequate erections following radical prostatectomy is certainly high. Nerve-sparing procedures during performance of this operation are encouraged as the incidence of erectile dysfunction is lower if one or both nerves are spared. If the patient is already impotent before the procedure, medical treatments with oral agents, intraurethral compounds, or intracorporally injected medications may be more effective with the nerves intact. Early institution of medical therapy, specifically intracorporal injections, after 2 months postoperatively has resulted in a higher incidence of spontaneous return of erections at 1 year. Vacuum erection devices may be successful in restoring erections but extensive practice in their use is necessary, and they may be unappealing to many patients. A penile prosthesis will restore erections if the patient is so motivated for implantation of such a device. These are expensive and require invasive surgery, but satisfaction rates among patients and partners who have used them have been in the range of 85%, the highest satisfaction rate among all of the treatments of erectile dysfunction.     

Continence after radical prostatectomy with bladder neck preservation.

PURPOSE: Bladder neck preservation during radical prostatectomy has been advocated for improving urinary continence. We evaluate bladder neck preservation looking at continence rates, surgical cancer control and bladder neck contracture. MATERIALS AND METHODS: A total of 40 patients underwent retropubic radical prostatectomy for clinically localized carcinoma of the prostate. The prostatic urethra was dissected in continuity with the bladder away from the lumen of the prostate, which allows for a true urethra-to-urethra anastomosis. RESULTS: Continence was noted immediately in 26 patients, within 2 weeks in 9 and within 6 weeks in 3. Only 2 patients required pads 3 months postoperatively. Microscopic positive surgical margins were noted in 2 of 40 patients. In 1 patient the urethral margins were not involved with carcinoma. In the other patient the urethra was not the sole positive margin and microscopic positive margins were noted elsewhere. Early results of cancer control were good. CONCLUSIONS: Early follow-up of this technique of radical retropubic prostatectomy suggest that preservation of the continence mechanism at the level of the bladder neck and prostatic urethra results in significantly improved postoperative urinary continence without adversely affecting cancer control.     

Salvage radiotherapy for PSA failure after radical prostatectomy.

BACKGROUND AND PURPOSE: Prostate-specific antigen (PSA) failure after radical prostatectomy is a common clinical scenario, and there is no consensus on how it should be managed. Salvage radiation to the prostatic bed is a potentially curative treatment option, and is the subject of this review. Patient selection, and the efficacy and toxicity of treatment will be discussed, and recommendations made for current practice and future studies. METHODS: An English language MEDLINE search was performed, limited to the years 1989-2000, using the MeSH headings 'prostatic neoplasms' and 'radiotherapy'. The 660 abstracts identified were reviewed, and articles concerning patient selection for, or outcome of, post-operative radiation to the prostatic bed selected. After exclusion of articles concerning adjuvant, rather than salvage, radiation, this left a total of 22 case series, including 1062 patients for the review of treatment efficacy. RESULTS AND CONCLUSIONS: The quality of the evidence makes it difficult to form a judgment regarding the efficacy of salvage radiation following radical prostatectomy, particularly in men with a PSA level in the range 0.01-0.2 ng/ml. Salvage radiation may be more effective given earlier rather than later. These considerations have important consequences for the interpretation of current trials of adjuvant radiation following radical prostatectomy.     

Hormonal manipulation for rising PSA after radical prostatectomy.

PSA recurrence after radical prostatectomy usually indicates recurrent prostate cancer. Identification of the recurrence site is difficult, but pathological and clinical features may suggest local versus distant recurrence. Radiographic techniques including transrectal ultrasonography, and 111indium capromab pendetide scans may help identify recurrences. The use of hormonal manipulation for rising PSA after radical prostatectomy is controversial. Androgen deprivation has been a mainstay of the management for advanced prostate cancer. The timing of such therapy is debatable, and early therapy in an asymptomatic patient may not correlate with improved survival. Maximal androgenic blockade with castration and nonsteroidal antiandrogens may offer a modest survival benefit in selected patients. Novel potency-sparing therapies with antiandrogens and finasteride afford an improved patient lifestyle, with questionable effects on survival. Intermittent androgen suppression is an experimental treatment modality that may reduce the side effects of castration. Ongoing studies are being performed to clarify these controversies, and the variety of treatment options allows patients great flexibility in considering quality of life and effective cancer control.     

Postoperative radiation therapy after radical prostatectomy for prostate carcinoma.

BACKGROUND. The role and benefit of adjuvant radiation therapy after radical prostatectomy is unclear. This role was evaluated in 58 patients who, after undergoing radical prostatectomy for prostate carcinoma, had local extension of disease beyond the prostate or positive surgical margins. Thirty-nine patients treated surgically alone were compared with 19 patients who received adjuvant postoperative radiation therapy. All patients were followed for at least 5 years, and 50 patients had 10-year follow-ups. RESULTS. At 10 years, the actuarial local failure rate was 31% for patients treated with prostatectomy alone versus 6% for the group receiving postoperative radiation therapy (P less than 0.05). The actuarial survival and metastasis-free survival were similar for both groups. When patients with involved lymph nodes were excluded from analysis, the addition of radiation therapy resulted in improved recurrence-free survival (91% versus 46% at 10 years, P = 0.04) and in a trend toward improved metastasis-free survival (91% versus 55%, P = 0.08). Complications occurred in similar frequencies in both groups. CONCLUSIONS. In patients with local disease extension or positive surgical margins after radical prostatectomy, adjuvant radiation therapy improved local control and was administered with acceptable side effects.     

The CAPRA-S score: A straightforward tool for improved prediction of outcomes after radical prostatectomy

BACKGROUND:

The authors previously developed and validated the Cancer of the Prostate Risk Assessment (CAPRA) score to predict prostate cancer recurrence based on pretreatment clinical data. They aimed to develop a similar postsurgical score with improved accuracy via incorporation of pathologic data.

METHODS:

A total of 3837 prostatectomy patients in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE?) national disease registry were analyzed. Cox regression was used to determine the predictive power of preoperative prostate‐specific antigen (PSA), pathologic Gleason score (pGS), surgical margins (SM), extracapsular extension (ECE), seminal vesicle invasion (SVI), and lymph node invasion (LNI). Points were assigned based on the relative weights of these variables in predicting recurrence. The new postsurgical score (CAPRA‐S) was tested and compared with a commonly cited nomogram with proportional hazards analysis, concordance (c) index, calibration plots, and decision‐curve analysis.

RESULTS:

Recurrence appeared in 16.8% of the men; actuarial progression‐free probability at 5 years was 78.0%. The CAPRA‐S was determined by adding up to 3 points for PSA, up to 3 points for pGS, 1 point each for ECE and LNI, and 2 points each for SM and SVI. The hazard ratio for each point increase in CAPRA‐S score was 1.54 (95% confidence interval, 1.49‐1.59), indicating a 2.4‐fold increase in risk for each 2‐point increase in score. The CAPRA‐S c‐index was 0.77, substantially higher than 0.66 for the pretreatment CAPRA score and comparable to 0.76 for the nomogram. The CAPRA‐S score performed better in both calibration and decision curve analyses.

CONCLUSIONS:

The CAPRA‐S offers good discriminatory accuracy, calibration, and ease of calculation for clinical and research settings. Cancer 2011;. © 2011 American Cancer Society.     

Recovery of urinary continence after radical prostatectomy

Introduction: In the era of minimally-invasive surgery, urinary incontinence (UI) after radical prostatectomy (RP) still represents a troublesome issue for a considerable rate of patients. Factors associated with the risk of post-RP UI, need to be carefully assessed throughout the overall clinical management process thus including the pre-operative, intra-operative and post-operative setting.

Areas covered: This review analyses current published evidences regarding clinical and surgical aspects associated with urinary continence (UC) recovery after RP. A careful evaluation of patient’s clinical characteristics should be carried out before surgery in order to properly counsel the patients regarding the risk of UI. In the last two decades, the advent of robotic surgery has led to an overall improvement of functional outcomes after RP, thanks to the development of different surgical strategies based on either the ‘preservation’ or the ‘reconstruction’ of the anatomical elements responsible for urinary continence.

Finally, several therapeutic strategies including either a conservative approach, or pharmacological and surgical treatments, should be carefully considered for the post-operative management of UI.

Expert commentary: A comprehensive pre-operative patient’s clinical assessment, along with a proper and well-conducted surgical procedure and an effective post-operative care management are essential element to achieve a high probability of UC recovery.     

Defining prostate cancer risk after radical prostatectomy

Prostate cancer encompasses a wide spectrum of tumor phenotypes with differing prognoses and a part of these patients are at risk of experiencing tumor recurrence after initial treatment. This review discusses the parameters that determine PCa risk for failure after radical prostatectomy and also focuses on the ability of currently available post-treatment nomograms to predict treatment outcomes, and probability of treatment failure. The use of predictive nomograms may be therefore helpful in the complex decision making process.     

pT0 prostate cancer after radical prostatectomy

The purpose of our study was to perform a literature review of current data to determine the frequency and correlates of pT0 prostate cancer after radical prostatectomy alone. A comprehensive search was made of MEDLINE and PUBMED. Seven studies were identified involving 18,135 patients with 74 reported pT0 cases. The most frequent correlates from our pooled data of patients with pT0 specimens include preoperative PSA <10 ng/ml, only one positive core biopsy, and Gleason score <7. J. Surg. Oncol. 2010;102:331–333. © 2010 Wiley‐Liss, Inc.