ANDROGEN DEPRIVATION WITH SALVAGE SURGERY FOR RADIORECURRENT PROSTATE CANCER: RESULTS AT 5-YEAR FOLLOWUP

Purpose

We studied the effect of the combination of androgen deprivation with salvage surgery in patients with radiorecurrent prostate cancer.

Materials and Methods

Salvage cystoprostatectomy or radical prostatectomy was performed in 29 patients with radiorecurrent prostate cancer. Of the 29 patients 24 had been treated with neoadjuvant hormonal therapy before salvage surgery, while in 5 an initial trial of androgen deprivation had failed preoperatively.

Results

The positive surgical margin rate for all patients was 31%. Margin involvement correlated strongly with disease specific and disease-free survival. At a mean followup of 5.3 years disease specific survival was 95% in men with negative surgical margin compared with 44% in those with positive surgical margins (p = 0.002). Similarly, clinical and biochemical disease-free survival was 80% in patients with negative surgical margins, while only 44% of those with positive surgical margins remained disease-free (p = 0.05). Surgical margins were positive in 80% of the men in the androgen deprivation failure group and in 21% in the neoadjuvant hormonal therapy group (p = 0.001). The disease specific survival rate after an initial trial of androgen deprivation failed was only 20% compared with 92% after neoadjuvant hormonal therapy was given preoperatively (p = 0.001).

Conclusions

The combination of neoadjuvant hormonal therapy with salvage surgery for radiorecurrent prostate cancer resulted in a low incidence of surgical margin involvement, which correlated strongly with disease specific and disease-free survival. Patients with radiorecurrent prostate cancer in whom an initial trial of androgen deprivation fails appear to be poor candidates for salvage prostatectomy.     

FAMILIAL PROSTATE CANCER: A DIFFERENT DISEASE?

Purpose

We analyzed the outcome after radical prostatectomy of patients with familial prostate cancer versus patients with sporadic prostate cancer.

Materials and Methods

The study included 720 patients with prostate carcinoma who were treated with prostatectomy between 1987 and 1996. Patients were excluded from the study if they had received adjuvant or neoadjuvant treatment, or had no available pretreatment prostatic specific antigen (PSA) level, no available biopsy Gleason score, incomplete pathological information or no available followup PSA levels. The analysis was performed on 529 cases. Patients were considered to have a positive family history for prostate cancer when the index patient confirmed the diagnosis of prostate cancer in a first degree relative (brother or father). The outcomes of interest were biochemical relapse-free survival, local failure and distant metastases. Proportional hazards were used to analyze the effect of family history and confounding variables (that is age, stage, biopsy Gleason score, initial PSA levels, surgical specimen Gleason score, extracapsular extension, lymph node metastasis, seminal vesicle invasion and surgical margin involvement) on treatment outcome.

Results

Median followup was 30 months. Of all cases 12% had a positive family history. Younger age was the only factor associated with positive family history, with 18% of patients younger than 65 years having a positive family history versus 6% of older patients (chi-square p <0.001). The 5-year biochemical relapse-free survival rate for the entire group was 64%. The 5-year biochemical relapse-free survival rates for patients with negative family history versus positive history were 66% and 46%, respectively (p = 0.001). A multivariate time-to-failure analysis using the proportional hazards model was performed based on family history, age (less than 65 versus 65 to 69 versus 70 or greater, initial PSA (10 or less versus greater than 10), biopsy Gleason score (6 or less versus 7 or greater), clinical T stage (T1-T2 versus T2B-C), prostatectomy specimen Gleason score (6 or less versus 7 or greater), extracapsular extension, seminal vesicle involvement, surgical margin involvement and lymph node involvement. After adjusting for the potential confounding factors, positive family history remained strongly associated with biochemical failure. The clinical failure rate for the entire group was 14%. The 5-year local failure rate was 7%, with positive surgical margins being the only independent predictor of local failure. The 5-year distant metastasis rate was 8%, with family history and initial PSA levels being independent predictors of distant relapse.

Conclusions

Our study suggests that patients with a familial prostate cancer have a higher likelihood of biochemical failure after radical prostatectomy than patients with sporadic cancer. This effect is independent of pretreatment or pathological factors. Our results suggest that the higher failure rates associated with familial prostate cancer are mainly secondary to higher distant relapse rates, and that familial prostate cancer may be more biologically aggressive than sporadic cancers.     

Randomized Study of Neoadjuvant Testicular Androgen Ablation Therapy Before Radical Prostatectomy in Men with Clinically Localized Prostate Cancer

Purpose

We determined whether 12 weeks of neoadjuvant testicular androgen ablation therapy using a luteinizing hormone-releasing hormone agonist could improve pathological outcomes in men undergoing radical retropubic prostatectomy for clinically localized (stages T1C, T2A and T2B) prostatic carcinoma.

Materials and Methods

A total of 56 participants was randomized to receive either monthly injections of a luteinizing hormone-releasing hormone agonist at 4-week intervals followed by radical retropubic prostatectomy (28) or to undergo immediate radical retropubic prostatectomy alone (28). Operations were performed via a similar technique and all prostatic specimens were processed histologically in their entirety.

Results

There was no improvement in pathological outcome using a luteinizing hormone-releasing hormone agonist preoperatively compared to surgery alone. Of 28 men undergoing immediate radical retropubic prostatectomy 23 had organ-confined (17) or specimen-confined (6) disease versus 22 of 28 who received luteinizing hormone-releasing hormone neoadjuvant therapy for 12 weeks preoperatively (16 with organ-confined and 6 with specimen-confined disease, p = 1.00). In addition, when the study population was analyzed by pretreatment prostate specific antigen (PSA) levels (10 ng./ml. or less, or greater than 10 ng./ml.) there was also no difference in pathological outcome (p = 0.65 for PSA greater than 10 and p = 0.32 for PSA less than 10).

Conclusions

Neoadjuvant androgen ablation therapy for 12 weeks before radical prostatectomy in patients with clinically localized adenocarcinoma of the prostate does not result in improved pathological outcomes.     

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

Purpose

We compare the incidence of positive surgical margins in patients who underwent perineal or retropubic radical prostatectomy for clinically localized (stage T1, T2) prostate cancer.

Materials and Methods

In this retrospective, nonrandomized study we reexamined the specimens of 94 consecutive patients who underwent radical perineal (48) or retropubic (46) prostatectomy for clinically localized prostate cancer (stage T1, T2) and with pathological stage pT2 (intracapsular), pT3A (established extracapsular extension without positive margins) or pT3B (extracapsular extension with positive margins) without lymph node involvement (N0). We assessed the presence or absence of extracapsular cancer with or without positive margins, incisions of the prostatic capsule exposing cancer (surgically induced positive margins) or benign glandular tissue. Patients were followed for 3 to 66 months (mean 25) using an ultrasensitive prostate specific antigen assay with a lower detection limit of less than 0.05 ng./ml.

Results

The overall incidence of positive margins in cancer tissue was 56% in the perineal and 61% in the retropubic group, and biochemical failure-free survival was 67% each. However, surgically induced positive margins in patients with organ confined disease were more frequent in the perineal than retropubic group (43 versus 29%, p <0.05) and associated with a 37% risk of biochemical failure (prostate specific antigen greater than 0.1 ng./ml.) at mean followup. In addition, capsular incisions exposing benign tissue were more frequent in the perineal than retropubic group (90 versus 37%, p <0.05) irrespective of pathological stage.

Conclusions

Although overall positive margins and biochemical failure rates are similar or identical for the perineal and retropubic approaches for organ confined prostate cancer, the perineal approach is associated with a significantly higher risk of capsular incisions and surgically induced positive margins and, thus, a higher risk of biochemical failure.     

Randomized, Prospective, Controlled Study Comparing Radical Prostatectomy Alone and Neoadjuvant Androgen Withdrawal in the Treatment of Localized Prostate Cancer

Purpose

A prospective, multicenter, randomized study was done to test the hypothesis that neoadjuvant androgen withdrawal decreases the incidence of positive margins following radical prostatectomy for localized prostate cancer.

Materials and Methods

Observations were made of 213 patients randomized to undergo radical prostatectomy alone (101) or to receive a 12-week course of 300 mg. cyproterone acetate daily followed by surgery (112). Groups were similar at baseline in terms of clinical stage, serum prostate specific antigen and Gleason score. Of 192 patients available for efficacy analysis 9 had stage T1b, 8 stage T1c, 63 stage T2a, 36 stage T2b and 76 stage T2c disease.

Results

One or more positive surgical margins were found in 59 of 91 patients (64.8 percent) in the surgery only group compared to 28 of 101 (27.7 percent) in the cyproterone acetate group (p = 0.001). Patients who received preoperative therapy had a statistically significantly lower rate of apical margin involvement than those who did not (17.8 versus 47.8 percent, respectively, p less than 0.0001). There was no statistically significant difference in surgical (p = 0.8645) or postoperative (p = 0.173) complications between the 2 groups.

Conclusions

Neoadjuvant androgen withdrawal with a 12-week course of 300 mg. cyproterone acetate daily results in a lower rate of positive margins without adversely affecting postoperative recovery. The impact on patient survival will be determined by long-term followup.     

Wide Excision (Nonnerve Sparing) Radical Retropubic Prostatectomy Using an Initial Perirectal Dissection

Purpose

Positive surgical margin rates after radical retropubic prostatectomy are reported to range from 25 to 50% in contemporary series. We report on 53 nonnerve sparing radical retropubic prostatectomies performed with attention paid to extending the margin of attached periprostatic tissue. This was accomplished primarily by initial perirectal release of periprostatic tissues at the level of longitudinal rectal fibers posterior and lateral of the prostate. This perirectal release ensures that maximal quantities of periprostatic tissue will remain with the prostate specimen and will not be attenuated or sheared away at subsequent stages of the procedure.

Materials and Methods

Pathological material was examined for capsular penetration and surgical margins using transverse whole mount sections of the prostate at 4 to 5 mm. intervals. Patients were followed at regular intervals with physical examinations and serum prostate specific antigen (PSA) determinations.

Results

The series consisted of 6, 5, 14 and 28 cases of clinical stages T1b, T1c, T2a and T2b cancer, respectively. Mean PSA was 10.0 ng./ml. and mean Gleason score was 5.9. Capsular penetration was observed in 47 of 53 cases (89%) and positive surgical margins were noted in 7 (13%). With a median followup of 3.61 years 2 patients experienced PSA defined recurrence.

Conclusions

We believe that positive surgical margin rates may be decreased when technical modifications are directed at increasing the amount of periprostatic tissue excised with the surgical specimen.     

SURGICAL MODIFICATIONS OF RADICAL RETROPUBIC PROSTATECTOMY TO DECREASE INCIDENCE OF POSITIVE SURGICAL MARGINS

Purpose

We sought to determine whether recent surgical modifications in the technique of radical retropubic prostatectomy decrease the incidence of positive surgical margins.

Materials and Methods

We reviewed the records of 144 consecutive patients a mean of 60.8 years old who underwent radical retropubic prostatectomy using a modified surgical technique. Mean prostate specific antigen was 8.6 ng./ml. and mean Gleason grade was 5.8. Surgical modifications included division of the dorsal venous complex of the penis 10 to 15 mm. distal to the prostatic apex; transection of the urethra 3 mm. beyond the prostatic apex; division of the anterior aspect of the urethra, leaving the investing periurethral musculature intact, and division of the posterior aspect of the urethra en bloc with the striated urethral sphinter; sharp dissection of the rectourethralis muscle and remaining attachments of the prostate to the rectum; wide excision of the neurovascular bundle posterolateral to the prostate when adjacent induration or tumor is present, and division of the bladder neck, leaving a 5 mm. cuff of bladder tissue with the prostate.

Results

Of 144 consecutive patients 16 (11.1%) had positive surgical margins at a total of 20 sites, including 7 (35%) at the apex, 8 (40%) posterolateral, 3 (15%) anterior and 2 (10%) at the bladder neck. These results compare favorably with the positive surgical margin rates after radical prostatectomy previously reported in the literature.

Conclusions

These surgical modifications appear to have decreased the incidence of positive surgical margins after radical retropubic prostatectomy.     

Malignant Cytological Washings from Radical Prostatectomy Specimens: A Possible Mechanism for Local Recurrence of Prostate Cancer Following Surgical Treatment of Organ Confined Disease

Purpose

Local recurrence of prostate cancer following complete and successful resection of organ confined disease has been variably reported in men. We hypothesized that observed secretions from the cut distal urethra during radical prostatectomy may contain malignant prostatic epithelial cells and contribute to this problem.

Materials and Methods

A prospective study was done of prostate cytology specimens from 50 consecutive men with clinically organ confined adenocarcinoma of the prostate undergoing radical retropubic or radical perineal prostatectomy. Direct cytological evaluation by 1 examiner was used to identify malignant or benign cells in these washings.

Results

Of 33 radical perineal and 17 radical retropubic prostatectomy specimens organ confinement was confirmed in 58 percent. Malignant prostatic epithelial cells were observed in 24 percent of all cytology specimens. Of cytological washings from prostates with pathologically confirmed organ confined cancers 17 percent showed malignant cells. While perineural invasion was noted in a majority of tumors with positive washings, only Gleason grade was a statistically significant predictor of recurrence (p = 0.009). Surgical approach did not alter the rate of positive cytology.

Conclusions

Malignant prostatic epithelial cells can be identified in the prostatic washings from men with pathologically organ confined prostate cancer. Surgical approach did not change the cytological findings. Gleason grade is a statistically significant predictor of cytological malignancy. These cells may represent a mechanism of failure following successful radical prostatectomy.     

Do Close but Negative Margins in Radical Prostatectomy Specimens Increase the Risk of Postoperative Progression?

Purpose

When tumor extends close to the margin of resection yet does not extend to the inked edge of the gland, it is unclear whether patients have an adverse prognosis compared to cases with greater distance between the tumor and margin.

Materials and Methods

Among radical prostatectomy specimens with negative margins the distance between the most peripheral tumor and the surgical margin of resection was measured in 52 cases with and 49 without progression. All patients had clinically confined disease (stages T1 or T2) with subsequent progression or a minimum 5-year followup without evidence of disease. No patient received preoperative or postoperative radiotherapy or hormonal therapy until progression occurred. All men underwent a postoperative serum prostate specific antigen test to evaluate progression. Seminal vesicles and lymph nodes were pathologically free of tumor. All prostates were serially sectioned, completely embedded and assessable regarding margins of resection.

Results

Patients with progression were no more likely to have tumor close to the margin than those without progression. In a regression analysis analyzing the effect of Gleason score, distance between tumor and margin, location of closest margin and pathological stage as related to progression, only grade was predictive of progression (p <0.00001).

Conclusions

It is not necessary for pathologists to designate these margins as close, since biologically this finding has no significance. Furthermore, physicians who are involved in treatment of patients after radical prostatectomy for prostate cancer should not alter therapy depending on whether margins are reported as close.     

Radical Prostatectony with Preservation of Urinary Continence

Purpose

In an effort to improve postoperative urinary continence after radical retropubic prostatectomy, a new operation to preserve the bladder neck and a significant portion of the prostatic urethra has been developed.

Materials and Methods

The prostatic urethra is dissected in continuity with the bladder away from the lumen of the prostate, which allows for a true urethra-to-urethra anastomosis.

Results

A total of 24 patients who underwent the new continence sparing radical retropubic prostatectomy was compared retrospectively to 80 who previously underwent a nerve sparing procedure. Total continence was noted immediately in 11 patients, within 9 days in 15 and within 7 weeks in 21 of 24 who underwent the new operation, compared to 1, 5 and 33, respectively, of 80 who underwent the standard operation. Microscopic positive margins were noted in 2 of 24 patients with the new continence sparing operation. Early results of cancer control were good.

Conclusions

Early followup of this new 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.     

SECULAR CHANGES IN RADICAL PROSTATECTOMY UTILIZATION RATES IN OLMSTED COUNTY, MINNESOTA 1980 TO 1995

Purpose

We estimated the changes in utilization of radical prostatectomy for treatment of prostate cancer and describe the clinical characteristics of men undergoing radical prostatectomy in a population based setting.

Materials and Methods

The Rochester Epidemiology Project was used to identify all Olmsted County residents who underwent radical prostatectomy from 1980 to 1995. The community medical records of these men were reviewed to determine the clinical and pathological stage and grade at biopsy and following surgery.

Results

From 1980 to 1995, 311 radical prostatectomies were performed on Olmsted County men. From 1980 to 1987 prostatectomy rates ranged from 6.3 to 31.0/100,000 men but rates increased dramatically to 53.6/100,000 in 1988 and 106.2/100,000 in 1992. The rate after 1992 decreased to 53.0/100,000 and then increased slightly to 80.4/100,000. There was a shift to younger age in more recent times (mean patient age 65.4 years in 1980 to 1986 and 62.4 in 1993 to 1995, p = 0.02), a nonsignificant (p = 0.10) trend toward lower pathological stage in recent years (42% stage pT2 in 1980 to 1986 versus 55% in 1993 to 1995) and a significant decrease in the proportion of cases of disease up staged following surgery (53% in 1980 to 1986 versus 37% in 1993 to 1995, p = 0.03). There was no significant trend in pathological grade with time (63% Mayo grade I or II in 1980 to 1986 versus 52% in 1993 to 1995, p = 0.30).

Conclusions

These findings demonstrate an increase in radical prostatectomy rates that coincided with increases in prostate cancer incidence. There was a decrease in population prostatectomy rates in 1993 which was followed by modest increases to levels lower than the peak in 1992. However, the clinical characteristics of patients during this period did not change dramatically, suggesting that in a population based setting the selection factors for patients undergoing surgical treatment may not have changed.     

PROGNOSTIC IMPLICATIONS OF A POSITIVE APICAL MARGIN IN RADICAL PROSTATECTOMY SPECIMENS

Purpose

We evaluated the prognostic implication of a positive surgical margin at the prostatic apex to define the risk of failure after radical prostatectomy.

Materials and Methods

Radical prostatectomy specimens of 590 patients operated on between 1990 and 1994 were reviewed by 2 uropathologists (D. G. and W. S.) to determine the percentage of patients with a positive margin at the apex in the absence of positive margins, extraprostatic extension or involvement of seminal vesicles and pelvic lymph nodes. In this group of 33 patients, the significance of a positive apex could be determined without the influence of any other stage related prognostic factors. Treatment failure was defined as prostate specific antigen greater than 0.4. All 33 patients have been followed between 3.5 and 65.5 months (median 38.7).

Results

Among 590 patients 236 (40%) had disease completely confined to the prostate. A total of 217 patients (37%) had either positive surgical margins (M+) or extraprostatic extension and of these, only 33 (5.5%) had an apical positive margin in an otherwise prostate confined tumor. Of 33 apical positive margin patients only 3 in whom surgery failed had a progressively detectable prostate specific antigen 3.5 to 65.5 months after surgery.

Conclusions

A positive surgical margin at the prostatic apex in the absence of positive margins or extraprostatic extension elsewhere does not confer a worse prognosis than organ confined disease. In this study the recurrence rate for patients with positive apical margins was the same as for those with confined disease.     

Laparoscopic radical prostatectomy: Initial short-term experience

Objectives

To determine the feasibility and efficacy of a laparoscopic approach to the radical retropubic prostatectomy (RRP).

Methods

A transperitoneal laparoscopic technique was developed to perform an RRP. Intra-abdominal access was obtained through five 10-mm trocars. After dissection of the prostate, the urethrovesical anastomosis was created via a transvesical approach. The prostate was removed by extending the umbilical incision.

Results

Between September 1991 and May 1995, nine laparoscopic RRPs were performed. The operative time averaged 9.4 hours. Only 1 of 9 patients had a positive surgical margin that involved the urethra. Six of 9 patients were completely continent postoperatively. Of the 4 patients who were potent preoperatively, 2 continued to have erections. There were three complications: cholecystitis, thrombophlebitis associated with a pulmonary embolism, and a small bowel hernia into a trocar site.

Conclusions

Laparoscopic radical prostatectomy is feasible but currently offers no advantage over open surgery with regard to tumor removal, continence, potency, length of stay, convalescence, and cosmetic result.     

LOCALLY RECURRENT PROSTATE TUMORS FOLLOWING EITHER RADIATION THERAPY OR RADICAL PROSTATECTOMY HAVE CHANGES IN KI-67 LABELING INDEX, P53 AND BCL-2 IMMUNOREACTIVITY

Purpose

We compare the biological phenotype of recurrent prostatic tumors after definitive local therapy (radiation or radical prostatectomy) with that of the same tumors before treatment.

Materials and Methods

Cellular proliferation (Ki-67 labeling index), p53 nuclear reactivity and bcl-2 immunoreactivity were determined in pretreatment and posttreatment tumor specimens from 13 patients with local tumor recurrence following radiation, and in 18 patients with local tumor recurrence following radical prostatectomy.

Results

Mean Ki-67 labeling index increased approximately 2-fold in locally recurrent tumors after radiation (10.5 versus 5.6%, p = 0.0008) or surgery (6.0 versus 3.2%, p = 0.0025) when compared with pretreatment tumors. We noted p53 nuclear reactivity in a significantly higher proportion of recurrences than in pretreatment tumors following radiation (54 versus 8%, p = 0.032) and surgery (39 versus 5%, p = 0.022). Although bcl-2 immunoreactivity was also seen in a higher proportion of recurrent tumors, this difference did not reach statistical significance for either radiation or surgery.

Conclusions

Recurrent tumors following either radiation or surgery differ significantly from the corresponding pretreatment tumors with respect to cellular proliferation and p53 nuclear reactivity.     

Pathological Characteristics and Prognosis of Nonpalpable and Palpable Prostate Cancers with a Hybritech Prostate Specific Antigen of 4 to 10 ng./ml

Purpose

We compared the surgical pathological findings and postoperative course of patients with palpable and nonpalpable prostate cancers.

Materials and Methods

All patients with untreated prostate specific antigen (PSA) 4 to 10 ng./ml. who underwent radical prostatectomy between December 1984 and December 1993 were reviewed to select 61 with clinical stage T1c (nonpalpable) and 209 with stages T2a to c (palpable) disease.

Results

Nonpalpable cancers were smaller (2.99 versus 4.42 cc for palpable tumors), had smaller volumes of Gleason grade 4 or 5 cancer (0.66 versus 1.32 cc, respectively) and were less likely to have positive surgical margins (13 versus 22 percent, respectively) or significant (1 cm. or more) capsular penetration (10 versus 26 percent, respectively). Nonpalpable and palpable cancers had similar rates of seminal vesicle invasion (3.3 versus 4.3 percent, respectively) and positive lymph nodes (1.6 versus 0 percent, respectively). More than 90 percent of patients with nonpalpable cancer were biochemically cancer-free postoperatively, and the remainder were alive with disease after a mean followup of 25.1 months, compared to 69 percent disease-free, 28 percent alive with disease and 2.5 percent dead of prostate cancer after a mean followup of 43.8 months among those with palpable disease.

Conclusions

We conclude that nonpalpable prostate cancers are pathologically more favorable than palpable prostate cancers with PSA 4 to 10 ng./ml. Our preliminary results also indicate that nonpalpable cancers are less likely to recur postoperatively than palpable cancers with a similar PSA range.     

A centralized comparison of radical perineal and retropubic prostatectomy specimens: is there a difference according to the surgical approach?

PURPOSE: We performed a central review of pathology specimens from radical perineal and radical retropubic prostatectomies performed by a single surgeon. We determined whether differences exist in the 2 approaches in regard to the ability to obtain adequate surgical margins around the tumor and adequate extracapsular tissue around the prostate, and avoid inadvertent capsular incision. MATERIALS AND METHODS: The review included whole mount prostates from 60 patients who underwent radical retropubic prostatectomy and 40 who underwent radical perineal prostatectomy. The pathologist (N. S. G.) was blinded to the surgical approach. All prostatectomies were consecutive and performed by the same surgeon (H. J. K.). To ensure consistency of the pathological measurements patients were excluded from analysis if they had undergone preoperative androgen ablation or a nerve sparing procedure, leaving 45 retropubic and 27 perineal prostatectomy specimens for further evaluation. Pertinent clinical parameters were assessed and a detailed pathological analysis of each specimen was performed. RESULTS: In the retropubic and perineal groups 78% of the tumors were organ confined (stage pT2) with extracapsular extension (stage pT3) in the majority of the remaining patients. There was no significant difference in the positive margin rate for the retropubic and perineal procedures (16% and 22%, p = 0.53) or for Gleason 6 and 7 tumors only in the 2 groups (10% and 17%, respectively, p = 0.47). The capsular incision rate was 4% in each group. The distance of the tumor from the posterolateral margins and the amount of extracapsular tissue excised were equivalent in each group. Subgroups of patients with a prostate of less than 50 gm. and containing only low grade, low stage neoplasms were also analyzed. Subgroup analysis showed no difference in any variable. CONCLUSIONS: Radical perineal prostatectomy is comparable to radical retropubic prostatectomy for obtaining adequate surgical margins, avoiding inadvertent capsular incisions and excising adequate extracapsular tissue around tumor foci. Additional patient accrual and prostate specific antigen followup would further help validate the similar efficacy of the 2 surgical approaches as treatment for prostate cancer.     

Komplikationen bei radikalen retropubischen Prostatektomien anhand der Martin-Kriterien

Background

In 2002 the ten Martin criteria were proposed which should be met when reporting complications following surgery. Only a few studies have evaluated complication rates after open retropubic radical prostatectomy using these criteria. In this study we report on complications of open retropubic radical prostatectomy using the standardized Clavien-Dindo reporting methodology.

Patients and methods

The overall complication rate was 28.6% (907 of 3,172). We registered 1,069 medical or surgical complications in 907 patients. Of these, 714 complications were grade I (66.8%), 195 grade II (18.2%), 139 grade III (13%), and 17 grade IV (1.6%), respectively. The mortality rate (grade V) was 0.1% (4 of 3,172). Older age (hazard ratio 1.049, p=0.023) and a performed lymphadenectomy (hazard ratio 1.804, p=0.024) were independent predictors for high-grade complications (grade III or greater) on multivariate analysis.

Results

Between 08/2003 and 06/2010 complications of 3172 consecutive men who underwent open retropubic radical prostatectomy at a single center were recorded prospectively. Complications which occurred within a period of 30 days postoperatively were graded retrospectively according to the Clavien-Dindo classification. Clinical and histopathological risk factors were statistically evaluated for an association with complication grades. All 10 Martin criteria were fulfilled.

Conclusions

Using the Clavien-Dindo classification as a standardized reporting methodology, we observed an acceptable overall complication rate of 28.6%. In the majority (85% of all complications) lower grade complications occurred. In this series older age and a lymphadenectomy were risk factors for high-grade complications (III-V). A patient??s age remains an important factor when considering the indication for radical prostatectomy.