Alan M. Nieder

Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1,000 cases.

PURPOSE We critically examined the intraoperative and postoperative complications associated with radical retropubic prostatectomy in the modern era. MATERIALS AND METHODS Between April 18, 1994 and July 13, 2000, 1,000 men underwent radical retropubic prostatectomy performed by a single surgeon. The whole inpatient hospital medical record of 909 patients, the outpatient charts of 955 and a self-administered patient survey completed by 679 were reviewed by 2 data managers not involved in surgical management or followup care. In all 1,000 cases at least 1 of the 3 data sources was reviewed. RESULTS Mean patient age was 60.3 years. In 73%, 99.8% and 95.7% of cases serum prostate specific antigen was 10 ng./ml. or less, disease was clinical stage T1 or T2 and Gleason score was 7 or less, respectively, while 19.9% of pathological specimens showed positive margins. There were 8 intraoperative complications (0.8%). All 5 rectal injuries and the single ureteral injury were detected during the initial surgical procedure and repaired without sequelae. Only 14 men (1.4%) had any other complications during hospitalization. Until postoperative day 30, 4 pulmonary emboli (0.4%) with or without deep vein thrombosis and 5 myocardial infarctions (0.5%) developed. There were no intraoperative or in-hospital postoperative deaths and only 1 postoperative death secondary to myocardial infarction during the initial 30 days. Reexploration was done for hemorrhage and a disrupted anastomosis in 3 and 2 cases, respectively. Mean hospitalization was 2.3 days, 9.7% of patients required allogenic blood transfusion and 15 (1.5%) were rehospitalized. CONCLUSIONS Our series represents a rigorous assessment of the complications associated with radical retropubic prostatectomy. It shows that in the hands of an experienced urological surgeon, this procedure is associated with minimal intraoperative and postoperative morbidity. Of the patients 98% had no intraoperative or postoperative complications. Our series enables appropriate contemporary comparisons to be made with laparoscopic prostatectomy and radiation therapy. This outcomes analysis implies that radical retropubic prostatectomy cannot be assumed to have greater morbidity than radiation therapy and it sets a high standard for those advocating laparoscopic radical prostatectomy.

Radiation therapy for prostate cancer increases subsequent risk of bladder and rectal cancer: a population based cohort study.

PURPOSE Pre-prostate specific antigen era series demonstrated an increased risk of bladder cancer and rectal cancer in men who received radiotherapy for prostate cancer. We estimated the risk of secondary bladder cancer and rectal cancer after prostate radiotherapy using a contemporary population based cohort. MATERIALS AND METHODS We identified 243,082 men in the Surveillance, Epidemiology and End Results database who underwent radical prostatectomy or radiotherapy for prostate cancer between 1988 and 2003. We estimated the incidence rate, standardized incidence ratio and age adjusted incidence rate ratio of subsequent bladder cancer and rectal cancer associated with radical prostatectomy, external beam radiotherapy, brachytherapy, and a combination of external beam radiotherapy and brachytherapy. RESULTS The relative risk of bladder cancer developing after external beam radiotherapy, brachytherapy and external beam radiotherapy-brachytherapy compared to radical prostatectomy was 1.88, 1.52 and 1.85, respectively. Compared to the general United States population the standardized incidence ratio for bladder cancer developing after radical prostatectomy, external beam radiotherapy, brachytherapy and external beam radiotherapy-brachytherapy was 0.99, 1.42, 1.10 and 1.39, respectively. The relative risk of rectal cancer developing after external beam radiotherapy, brachytherapy and external beam radiotherapy-brachytherapy compared to radical prostatectomy was 1.26, 1.08 and 1.21, respectively. The standardized incidence ratio for rectal cancer developing after radical prostatectomy, external beam radiotherapy, brachytherapy and external beam radiotherapy-brachytherapy was 0.91, 0.99, 0.68 and 0.86, respectively. CONCLUSIONS Men who receive radiotherapy for localized prostate cancer have an increased risk of bladder cancer compared to patients undergoing radical prostatectomy and compared to the general population. The risk of rectal cancer is increased in patients who receive external beam radiotherapy compared to radical prostatectomy. Patients should be counseled appropriately regarding these risks.

Early removal of urinary catheter after radical retropubic prostatectomy is both feasible and desirable

OBJECTIVES To determine the feasibility and desirability of removing the urinary catheter 7 days after radical retropubic prostatectomy. METHODS Between February 28, 2000 and October 5, 2000, 184 men underwent radical retropubic prostatectomy by a single surgeon. Of these men, 97% underwent gravity cystography under fluoroscopic control on postoperative day (POD) 7. The indwelling urinary catheter was removed on POD 7 if no evidence of extravasation was observed on cystography. Patients completed a self-administered questionnaire at the time of catheter removal to capture the degree of bother from incisional pain and the indwelling urinary catheter during the recovery period. The level of urinary continence was determined at 3 months after radical retropubic prostatectomy. RESULTS One hundred thirty-five of the cystograms (75%) had no evidence of extravasation. The indwelling catheters were removed in 130 (97%) of 135 cases. The body weight, surgical specimen weight, presence or absence of intraoperative anastomotic extravasation, volume of pelvic drainage recorded from the Hemovac drain, and creatinine level of the pelvic drainage fluids did not predict the finding of extravasation on the POD 7 cystogram. Fifteen percent of the men whose catheters were removed on POD 7 developed acute urinary retention. At 3 months, 72% of men required no or a single protective pad, and 87% indicated they experienced no or slight bother from incontinence. These continence outcomes are comparable with a historical control group by the same surgeon who underwent catheter removal on POD 14. Forty-five percent of the men reported the catheter caused moderate to severe bother, compared with only 19% of men who indicated moderate to severe bother from incisional pain. In retrospect, 95.6% of men indicated willingness to undergo cystography on POD 7 with the intent of early catheter removal. CONCLUSIONS The results of our study suggest that most men will have no extravasation on a cystogram performed on POD 7 and that removing the catheter at this time in these cases does not increase the risk of complications or compromise overall urinary continence. The urinary catheter is a significant bother and limits physical activity during the postoperative period. Cystography and early removal of the catheter is both feasible and desirable and should be offered to men after radical retropubic prostatectomy.

Factors affecting erectile function after radical retropubic prostatectomy: results from 1620 consecutive patients.

To report the return of erectile function in 1620 consecutive men after radical retropubic prostatectomy (RRP), chosen by half of men diagnosed with clinically localized prostate cancer, and the goal of which is to completely excise the tumour while preserving continence and erectile function.

Urethral recurrence after cystoprostatectomy: Implications for urinary diversion and monitoring

OBJECTIVES To review our cystoprostatectomy (CP) database to determine the urethral recurrence rate. Urethral recurrence after CP has been reported to occur in up to 10% of patients. Recent data have suggested a much lower incidence. This has important implications when considering the type of urinary diversion and postoperative monitoring. METHODS We retrospectively analyzed our single-surgeon, consecutive CP series and determined the urethral recurrence rate and prognostic factors for recurrence. Urethrectomy was performed at CP if the prostatic apical margin was positive for carcinoma. All patients were followed up quarterly for 2 years and then semiannually. Urethral wash cytology was obtained if the patient had an ileal conduit. Cytology and cystoscopy were performed if they had an orthotopic neobladder. RESULTS A total of 226 men had undergone radical CP. The mean age for all patients was 69 years. Eight (3.5%) had undergone urethrectomy at CP. The mean follow-up was 42 months for the remaining 218 patients, of whom 108 had an orthotopic neobladder and 110 had supravesical diversion. Of the 218 patients, 8 (3.7%) developed urethral recurrence, 7 (6.4%) in the 110 who had undergone supravesical diversion and 1 in the 108 (0.9%) who had an orthotopic neobladder. Seven patients underwent urethrectomy for the recurrence and had no evidence of disease at last follow-up. One patient died of metastatic transitional cell carcinoma at 61 months. CONCLUSIONS In our series, the risk of urethral recurrence after radical CP was low. The risk was substantially lower for patients who had an orthotopic neobladder. Our results show that urethrectomy at CP is rarely necessary because the proximal urethral margin is usually free of cancer. An orthotopic neobladder can therefore be safely considered in most patients. Delayed urethrectomy can be safely performed in those few patients with isolated urethral recurrence without compromising their survival.

Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey.

INTRODUCTION Hematuria is a common finding that may be a sign of serious underlying urologic disease. Thus, the AUA guidelines (written in conjunction with the American Academy of Family Practice) recommend urologic evaluation for patients with both microscopic and gross hematuria. We sought to evaluate practice patterns of the evaluation of hematuria by primary care physicians (PCPs) in two locations in the United States. METHODS Anonymous questionnaires regarding use of urinalysis (UA) and evaluation of hematuria were mailed to 586 PCPs in Miami, Florida and 1,915 in Dallas, Texas. Surveys were mailed to physicians who identified themselves as practitioners of internal medicine, family practice, primary care, or obstetrics and gynecology. RESULTS Surveys were completed by 788 PCPs including 270 (46%) and 518 (26%) PCPs in Miami and Dallas, respectively. Screening UAs were obtained on all patients by 77% and 64%, of physicians in Miami and Dallas, respectively. In both Miami and Dallas, only 36% of PCPs reported referring patients with microscopic hematuria to an urologist. In patients with gross hematuria, referral rates were 77% and 69% in Miami and Dallas, respectively. CONCLUSIONS While many PCPs use UA in many of their patients routinely, few PCPs automatically refer their patients with microscopic hematuria to urology and not all patients with gross hematuria are referred. Further investigations regarding why and when patients are referred to urology is warranted. Increasing awareness of the complete and timely evaluation of hematuria may be beneficial in preventing a delay in bladder cancer.

Upper tract tumour after radical cystectomy for transitional cell carcinoma of the bladder: incidence and risk factors.

The considerable experience of the University of Miami in treating TCC is reviewed in the first article in this section. The authors found that the incidence of upper tract tumour after radical cystectomy for TCC is low, but that patients with prostatic urethral involvement at cystectomy have a greater risk of developing upper tract tumours.

Hand-assisted laparoscopy for large renal specimens: a multi-institutional study

OBJECTIVES To present our experience with hand-assisted laparoscopy (HAL) for larger renal specimens. One of the theoretical benefits of HAL is the ability to manage large renal specimens, which we defined as tumors greater than 7 cm, and tumors in obese patients. METHODS Between March 1998 and October 2000, 106 HAL radical nephrectomies were performed for enhancing renal masses, for which 95 patients had complete preoperative, intraoperative, and postoperative data. Of the 95 patients, 32 underwent HAL for large tumors (7 cm or greater) and 41 had a body mass index of 31 or greater. The demographic and outcome data of these two groups were compared with 63 patients who underwent HAL for tumors less than 7 cm and 54 patients with a body mass index of less than 31. RESULTS When comparing cohorts by tumor size, the only statistically significant differences were in convalescence and specimen weight. Patients with lesions 7 cm or greater required 21 days to recover compared with 18 days for patients with lesions less than 7 cm. Obese patients had statistically significantly higher American Society of Anesthesiologists classifications, longer operative times (214 versus 176 minutes), and longer convalescences (21 versus 17.5 days) compared with nonobese patients. The estimated blood loss and conversion rate was not different between the groups. Furthermore, no difference was noted between the groups in the incidence of positive margins, local recurrence, or metastatic recurrence at a mean follow-up of 12.2 months. CONCLUSIONS HAL provides a safe, reproducible, and minimally invasive technique to remove large renal tumors and renal tumors in the obese.

TOTAL PROSTATE AND TRANSITION ZONE VOLUMES, AND TRANSITION ZONE INDEX ARE POORLY CORRELATED WITH OBJECTIVE MEASURES OF CLINICAL BENIGN PROSTATIC HYPERPLASIA

PURPOSE We determined if total prostate volume, transition zone volume or transition zone index is correlated with the severity of clinical benign prostatic hyperplasia (BPH). MATERIALS AND METHODS A total of 93 men 52 to 85 years old, who were referred to a urology outpatient facility for treatment of clinical BPH, elevated serum prostate specific antigen or abnormal digital rectal examination, underwent measurement of total prostate and transition zone volume at transrectal ultrasonography. All men were requested to undergo uroflowmetry and complete the American Urological Association (AUA) symptom score. RESULTS The pairwise correlations between AUA symptom score, versus total prostate and transition zone volumes and transition zone index were not statistically or clinically significant. A weak pairwise relationship was observed between peak flow rate versus total prostate volume (r2 = 0.160), transition zone volume (r2 = 0.156) and transition zone index (r2 = 0.147). The pairwise relationships between AUA symptom scores versus all prostate volumes were not statistically significant for subjects with mild (score 8 or less) or moderate to severe (score more than 8) symptoms. CONCLUSIONS Total prostate and transition zone volumes, and transition zone index are not directly related to AUA symptom score and only weakly related to peak flow rate. These findings provide further evidence that the total prostate, total BPH and relative BPH volumes are not useful determinants of the severity of clinical BPH.

The role of partial nephrectomy for renal cell carcinoma in contemporary practice

Partial nephrectomy has proved to be a safe and effective treatment modality, even for patients with normal contralateral kidneys. The indications for elective partial nephrectomy continue to evolve as contemporary series demonstrate low morbidity approaching that of radical nephrectomy. Furthermore, patients who undergo partial nephrectomy have a significantly decreased risk of future renal insufficiency. As such, a rationale exists for expanding indications in an era of excellent technical outcomes and increased patient longevity. Characterization of newer diagnostic (three-dimensional imaging) and treatment (laparoscopic partial nephrectomy, cryosurgery) modalities will allow continued evolution of nephron-sparing techniques.