Anthropometric differences in obese men with biochemical failure after radical retropubic prostatectomy

ObjectiveThe effect of obesity on biochemical failure after radical retropubic prostatectomy (RRP) is controversial. The differences in study outcomes may be a result of using body mass index (BMI) rather then direct anthropometric measurements of fat distribution. To investigate these differences, we used endorectal coil MRI (eMRI) data to directly measure fat thicknesses in obese men who underwent RRP.MethodsWe performed a retrospective analysis on an RRP database of 1,987 men with available BMI, clinicopathologic characteristics, and biochemical follow-up. Obese men (BMI ≥ 30) were compared with normal weight men (BMI ≤ 25) and overweight men (BMI > 25, < 30) for clinical and pathologic differences and biochemical failure. The eMRI data for 143 obese men were reviewed and the fat thicknesses in the anterior, posterior, and total anteroposterior abdominal diameters were measured and averaged in 3 separate images at and around the midline in the widest segment of the sagittal T2 weighted localizing scans.ResultsKaplan Meyer curves with log rank analysis revealed a significant difference in biochemical free survival in lean men and overweight men compared with obese men (P = 0.016, P = 0.021). A BMI ≥ 30 did not predict time to biochemical failure on multivariate analysis (HR 1.02, 95% CI 0.67–1.56, P = 0.29). The anterior fat thickness on eMRI in obese men with biochemical failure (n = 21) was significantly smaller than obese men without biochemical failure (n = 122) (35 mm vs. 44 mm, P = 0.003). Calculated percent visceral fat thickness was also significantly larger in obese men with biochemical failure (74% vs.71%, P = 0.02). Subset analysis on patients with extracapsular extension and higher pathologic Gleason scores revealed similar trends in anterior and percent visceral fat thicknesses (P = 0.003, P = 0.02).ConclusionDifference in fat distribution may help account for some of the controversy surrounding obesity and prostate cancer. These differences may explain why BMI alone may not adequately predict the influence of obesity on outcomes of prostate cancer treatment.     

Robotic-assisted laparoscopic radical prostatectomy after aborted retropubic radical prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) has surged in popularity since US Food and Drug Administration approval in 2000. Advantages include improved visualization and increased instrument dexterity within the pelvis. Obesity and narrow pelves have been associated with increased difficulty during open retropubic radical prostatectomy (RRP), but the robotic platform theoretically allows one to perform a radical prostatectomy despite these challenges. We present an example of a RALP performed following an aborted RRP. A 49-year-old male with intermediate risk prostate cancer and body mass index of 38 kg/m² presented for RALP after RRP was aborted by an experienced open surgeon following incision of the endopelvic fascia due to poor visualization, a prominent pubic tubercle, and a narrow pelvis. The enhanced visualization and precision of the robotic platform allowed adequate exposure of the prostate and allowed us to proceed with an uncomplicated prostatectomy, which was not possible to perform easily via an open approach. The bladder was densely adherent to the pubis and the anterior prostatic contour and apex were difficult to develop due to a dense fibrotic reaction from the previous endopelvic fascia incision. However, we were able to successfully complete RALP with subtle technical modifications. Estimated blood loss was 160 mL and operating time was 145 min. The patient’s pathology was significant for a positive peri-prostatic lymph node and he has been referred to radiation oncology for adjuvant radiotherapy and androgen deprivation therapy. At 3 months follow-up he had a prostate-specific antigen level of 0.06 ng/mL, partial erections, and mild urinary incontinence requiring one pad per day. Superior intracorporeal laparoscopic visualization and improved instrument dexterity afforded by the robotic surgical platform may make RALP the preferred approach in obese men or men with difficult pelvic anatomy who are deemed poor RRP candidates.     

Clinical and pathological characteristics of patients presenting with biochemical progression after radical retropubic prostatectomy for pathologically organ-confined prostate cancer

INTRODUCTION: To identify risk factors for biochemical failure after radical prostatectomy (RP) in men with pathologically organ-confined (OC) prostate cancer (PCa). MATERIALS AND METHODS: Clinical and pathological features of 350 consecutive patients with pathologically OC PCa treated only with RP and bilateral pelvic lymphadenectomy were analyzed, retrospectively, to identify predictor parameters of prostate-specific antigen (PSA) failure (PSA>or=0.4 ng/ml). The median follow-up was 58.6 months (range: 3.9-183 months). All pathological specimens were step sectioned at 4-mm intervals. Kaplan-Meier progression-free survival rates and chi2 test were adopted for statistical analyses. Multivariate Cox proportional hazard regression models were used to test the association between pathological Gleason score and surgical margin status. RESULTS: 67 patients (19.1%) failed at a median follow-up of 40.2 months (range 1.9-123.3). Age and preoperative PSA failed to reveal significance also in patients with serum PSA>or=20 ng/ml (p=0.46). Patients with T3 clinical stage had a higher progression rate compared to T1C and T2 (43.5 vs. 27.8 and 17.3%, respectively) even if no high statistical significance was pointed out. Presence of perineural infiltration (p=0.04) and prostatic apex infiltration (p=0.74) in the prostatectomy specimens failed to reveal significance. A high pathological Gleason score (>or=7; p=0.0003) and surgical margin status (p<0.0001) were shown to be the most powerful predictive parameters of biochemical progression. CONCLUSIONS: In patients with pathologically OC PCa the presence of a high pathological Gleason score and positive surgical margins appear to represent the most important factors for prediction of outcome following RP.     

Spontaneous priapism after radical retropubic prostatectomy

We present the first case of priapism following radical prostatectomy. A 66-year-old man with normal erections underwent radical retropubic prostatectomy with unilateral nerve sparing. Pathology showed a pT2c pN0 Gleason score 3 + 3 = 6 prostate cancer and the postoperative course was uneventful. Ten days after surgery he recognized a spontaneous painful penile erection without sexual stimulation which occurred in a standing position and disappeared in a supine position. These episodes recurred several times during the next 3 weeks and then completely vanished. Pathophysiologically, we postulate intermittent position-depending venous obstruction due to local hematoma or thrombosis.     

The meaning of PSA progression after radical prostatectomy. Preliminary results

ObjectivesTo report our findings regarding to the natural history of prostate cancer (PCa) that shows recurrence after radical prostatectomy (RP), in terms of time to development of metastatic disease and death from PCa. To identify independent predictors of PSA recurrence.Material and methodsRetrospective analysis of 227 patients with clinically localized PCa who underwent RP. The event PSA recurrence was defined as the presence of a postoperative PSA level of 0,2 ng/ml or higher at least 3 months after surgery. Hence, cases with shorter follow-up time were excluded from analysis. No adjuvant therapy (radiotherapy or hormonal therapy) was performed in the included population.Recurrence free survival was calculated during the follow-up period (Kaplan-Meier analysis). Uni and multivariate study was performed in order to assess the ability of factors as preoperative PSA level, Gleason score in surgical specimen, capsular penetration, positive surgical margins (excluding urethral), extracapsular extension, positive pelvic lymph nodes, and seminal vesicle invasion, to predict PSA recurrence.Finally, we selected the group of patients with PSA recurrence and calculated the probability of being free from distant metastatic disease during the follow-up period. Also, function of disease-specific survival was calculated.ResultsA total of 208 records were finally included in the study. Median age was 61 years. A total of 47 (22.6%) presented with extracapsular extension. Median follow-up time was 35.8 months, and 49 (23.6%) developed PSA recurrence. Recurrence free survival was 79.9% and 67.4% at 2 and 5 years, respectively.Only three factors were identified with the aid of multivariate analysis as independent predictors of recurrence: preoperative PSA >= 10 ng/ml (hazard ratio –HR- 3.03), Gleason score in surgical specimen 8 or higher (HR 3.42), and the finding of capsular penetration (HR 2.17). When only patients with PSA recurrence were considered, 16.3% developed distant metastasis. Probabilities of being free from distant disease after PSA recurrence were 97.7% and 86.9% at 2 and 5 years respectively (actuarial median time 110.8 months). Only 2 patients died from PCa, therefore disease-specific mortality analysis was not performed.ConclusionsAlthough an important proportion of patients present with PSA recurrence after RP in our setting, the prognosis in term of development of metastatic disease is acceptable in the short-medium term. Anyway, further analysis will be needed to ascertain the evolution of these patients in the long term.     

Penile fibrotic changes after radical retropubic prostatectomy

OBJECTIVE: To investigate the type of penile deformity, response to treatment of and predictive factors for the formation of penile fibrotic changes after radical retropubic prostatectomy (RRP). PATIENTS AND METHODS: Between July 1996 and September 1998, 110 men who had undergone RRP a mean (SD, range) of 35 (20, 5-145) months previously were evaluated by one physician for their erectile dysfunction. Those men affected by penile fibrotic changes were advised to initiate medical therapy for possible Peyronie's disease; their charts were reviewed and they were interviewed to determine the outcome. RESULTS: Overall, 45 of 110 patients (41%) with erectile dysfunction after RRP had penile fibrotic changes, representing 11% of all patients undergoing RRP in the specified period. The primary clinical presentation included penile curvature in 42 men (93%) and 'waistband' deformity in 11 (24%; some had both); palpable plaques were present in 31 (69%). On assessing the outcome in 40 men, 16 (40%) felt that their condition had improved, half were unchanged and 10% progressed, within a mean follow-up of 24 months after diagnosis. Of the 16 improved, 14 were regularly using a vacuum constriction device or injection therapy. No significant factors predictive of the fibrotic changes could be identified, including the use of intracavernosal injection therapy before onset, neurovascular bundle resection, operative duration, estimated blood loss and pathological tumour grade or stage. CONCLUSIONS: Penile fibrotic changes are a significant but previously undescribed problem in men after RRP. Although predisposing factors could not be identified, most men felt that their condition stabilized or improved during treatment. Corroborative confirmation of this association and its aetiology will require prospective studies.     

Bladder neck contracture after radical retropubic prostatectomy

OBJECTIVE: To examine the incidence, management and outcome of vesico-urethral anastomotic strictures after bladder-neck sparing radical retropubic prostatectomy (RRP). PATIENTS AND METHODS: We assessed the incidence, management and outcome of anastomotic strictures in 510 consecutive patients (mean age 61 years, range 45-76) who had open RRP by one surgeon between 1994 and 2003. RESULTS: The mean (range) follow-up was 30 (2-89) months; 48 patients (9.4%) developed an anastomotic stricture. Dilatation of the stricture was an effective treatment, with few patients requiring further treatment. CONCLUSION: Stricture of the vesico-urethral anastomosis after bladder-neck sparing RRP is relatively frequent but can usually be successfully managed with one graduated dilatation under light sedation.     

Surgical margin status after radical retropubic prostatectomy

This month there are two mini-reviews on aspects of prostate cancer. The first, from the USA, presents the implications of surgical margin status after radical prostatectomy and the potential role of adjuvant radiation therapy. The second, from the USA and Belgium, discusses the use of hormonal therapy for PSA-only recurrence of prostate cancer after previous local therapy. In the third mini-review, the condition known as hypoactive sexual desire disorder is described, and that it is often ignored or erroneously treated as erectile dysfunction suggests to the authors that education of doctors and patients is required. Finally, there is a mini-review of conventional and alternative methods for providing analgesia in renal colic.     

Experience with early catheter removal after radical retropubic prostatectomy

PURPOSE: We tested the hypothesis that early catheter removal may be accomplished safely after radical prostatectomy. MATERIALS AND METHODS: Cystography on postoperative day 4 or 5 in 42 of 67 consecutive patients who underwent radical retropubic prostatectomy revealed no extravasation in 30 and the urethral catheter was removed (group 1). The control group included 25 patients who did not undergo cystography, and the catheter was removed 14 days postoperatively (group 2). RESULTS: Immediate and late continence was achieved in 14 (46.7%) and 25 (83.3%) cases in group 1, and in 8 (32%) and 22 (88%) cases in group 2, respectively (p>0.05). Catheterization was performed easily without any endoscopic or surgical procedure in 2 patients (6.7%) in group 1 who presented in urinary retention after catheter removal. Wound infection and pelvic abscess developed in 1 case (3.3%). There were no late complications. In group 2 urinary retention developed in 1 patient (4%), wound infection in 1 (4%) and hematuria in 1 (4%). Two patients (8%) had late vesical neck contracture at 4 and 10 months, respectively, which required urethrotomy in 1. In 1 patient (4%) a stricture in the anterior urethra was dilated. CONCLUSIONS: Our study shows that early catheter removal may be accomplished safely in most patients after radical retropubic prostatectomy, and was not associated with a higher complication rate.     

术前PSA倍增时间的长短对前列腺癌根治术后生化复发无明显影响

<正>前列腺癌根治术后PSA倍增时间被用来预测生化复发后肿瘤相关性致死率已被肯定,但术前PSA倍增时间与手术预后之间的关系却鲜为人知,作者通过对1208例经筛查确诊前列腺癌并接受根治术的患者进行研究,计算术前PSA倍增时间,并将其与肿瘤无生化进展期相比较。研究发现,PSA倍增时间与非实体肿     

High frequency of allelic losses in high-grade prostate cancer is associated with biochemical progression after radical prostatectomy

Loss of heterozygosity (LOH) is the most consistent genetic change in prostate cancer (CaP). We aimed, to correlate specific LOH and the overall LOH frequency, to disease progression after radical prostatectomy (RP) in high-grade CaP. Between January 1990 through December 1998, 126 patients who underwent RP (cT1-T2), Gleason 8-10, were pT3, or pN1, or SM(+) (surgical margins). Nine were lost of follow-up, 39/117 (33%) had no biochemical progression (mean follow-up: 45 months). After exclusion for preoperative PSA >50 ng/mL, a case-control study was designed by matching 26 of these cases with 26 similar patients without biochemical progression (criteria: pT, pN, year of surgery). Using microsatellite markers, LOH were assessed on six chromosomal regions (7q31, 8p22, 12p13, 13q14, 16q23.2, 18q21). No prognostic value was associated with LOH at any one specific locus. However, the overall LOH frequency (five classes, cutoff of 60%), was significantly higher if progression (P = 0.02; P = 0.03) in SM(+) patients, and was near statistical significance (P = 0.08; P = 0.07) for the overall case-control population. In multivariate analysis (overall population), the overall LOH rate > or =60% was independently associated with progression [P = 0.035; Odds Ratio (OR) = 5.54]. An overall LOH rate > or =60% predicted poor outcome in 85% of SM(+) patients and 69% of the whole population. Our results suggest that the overall rate of LOH at chromosomal "hot spots" is more likely to be predictive of recurrence than the presence of LOH at any one particular locus. Moreover, the identification of a threshold of LOH could help in predicting patients with poor outcome who may be candidates for local or systemic adjuvant therapies.