Eamonn Rogers

Risk Factors for Urinary Incontinence after Radical Prostatectomy

PURPOSEnWe identified risk factors associated with urinary incontinence after radical retropubic prostatectomy.nnnMATERIALS AND METHODSnThe time from operation until urinary continence was achieved was determined by chart review and questionnaire in 581 patients who were continent before undergoing radical retropubic prostatectomy between 1983 and 1994. Using univariate and multivariate analyses of data gathered prospectively, we examined risk factors associated with incontinence in these patients.nnnRESULTSnThe actuarial rate of urinary continence at 24 months was 91% for the entire patient population and 95% for those treated after 1990. Many factors were associated with the risk of incontinence in univariate Cox proportional hazards regression analysis (patient age and weight, degree of obstructive voiding symptoms, prior transurethral resection of the prostate, clinical stage, intraoperative blood loss, resection of neurovascular bundles, postoperative anastomotic stricture and technique of vesicourethral anastomosis). However, in a multivariate analysis the factors that were independently associated with increased chance of regaining continence were decreasing age, a modification in the technique of anastomosis (introduced in 1990), preservation of both neurovascular bundles and absence of an anastomotic stricture. With introduction of the new surgical technique in 1990 the median time to continence decreased from 5.6 to 1.5 months and the rate of continence at 24 months increased from 82 to 95%.nnnCONCLUSIONSnWhile the risk of urinary incontinence after radical prostatectomy is related to the uncontrollable factor of patient age, it is also sensitive to the surgical technique used.

Salvage Radical Prostatectomy: Outcome Measured by Serum Prostate Specific Antigen Levels

We reviewed our experience with salvage radical prostatectomy for locally recurrent cancer in 40 patients to assess the current complication rate and the results using prostate specific antigen (PSA) as an indicator of treatment outcome and to identify better criteria for the selection of appropriate candidates for this operation. Most recurrent cancers were detected by digital rectal examination (26 patients) or increasing serum PSA levels (10). The operation was technically challenging, with 6 rectal injuries (15%), 2 requiring temporary colostomy. Serious technical complications were more common (31%) among the 29 patients who underwent pelvic lymphadenectomy at the time of initial radiotherapy than among the 11 treated with external irradiation alone (9%). Urinary incontinence persisted in 18 of 31 evaluable patients (58%) and was successfully corrected with an artificial urinary sphincter in 9. A total of 21 patients (54%) had pathologically advanced disease (seminal vesicle invasion and/or lymph node metastases). Preoperative PSA levels but not clinical stage or biopsy grade correlated with pathological stage (p < 0.03). If the PSA was less than 10 ng./ml. only 15% of the patients had an advanced pathological stage, compared to 86% if the PSA was 10 or more. After 2 to 97 months (mean 39) 2 patients died of metastatic prostatic cancer, 5 had distant metastases and none had symptomatic local recurrence. At 5 years the actuarial nonprogression rate measured by PSA was 55 +/- 20%. The only pretreatment factor predictive of progression was the serum PSA level. If the PSA was less than 10 ng./ml. the actuarial rate of progression was significantly lower than if the PSA was greater than 10 (p < 0.05). The best results were in the subset of 18 patients with cancer confined to the prostate or immediate periprostatic tissue: 82% had no progression at 5 years. Within each of these pathological stages the results of salvage prostatectomy were similar to those for standard radical prostatectomy in patients with no prior irradiation. Although technically challenging, salvage prostatectomy provides excellent control of radio-recurrent cancer confined to the prostate or immediate periprostatic tissue and is best performed before the preoperative PSA level increases to greater than 10 to 20 ng./ml.

THE ROLE OF ORCHIECTOMY IN TH MANAGEMENT OF POSTPUBERTAL CRYPTORCHIDISM

PURPOSEnOwing to the risk of future malignancy, many postpubertal male subjects presenting with unilateral cryptorchidism undergo orchiectomy rather than orchiopexy. We examined the incidence of spermatogenesis and carcinogenesis in whole orchiectomy specimens removed from postpubertal cryptorchid male subjects. We review the concept that orchiectomy is justifiable in these patients.nnnMATERIALS AND METHODSnA total of 52 patients with postpubertal cryptorchidism (unilateral in 48, bilateral in 4) were retrospectively analyzed from 1984. Patient age ranged from 15 to 66 years (mean 26). Six patients presented with primary infertility (unilateral in 3, bilateral in 3). The undescended testicles were palpable in 32 cases (62%). All patients underwent unilateral orchiectomy and whole specimens were examined histologically.nnnRESULTSnHistology showed normal spermatogenesis in only 1 orchiectomy specimen, while 15 had maturation arrest, 6 testicular agenesis and 30 seminiferous tubular atrophy and/or Sertoli-cell-only syndrome with no spermatogenesis. The location of the undescended testis was the superficial inguinal pouch in 32 cases, inguinal canal in 6 and inside the deep ring in 8. Absent spermatogenesis was significantly associated with a high level of maldescent and with increasing age. Two patients (4%) had carcinoma in situ of the testicle. Torsion of an undescended testicle occurred in 1 patient (2%).nnnCONCLUSIONSnThis analysis of cryptorchid testes in postpubertal male subjects confirms that the majority cannot contribute to fertility, have significant malignant potential and may undergo torsion. Therefore, orchiectomy remains the treatment of choice for the majority of postpubertal male subjects presenting with unilateral cryptorchidism.

A Simple Ileal Substitute Bladder After Radical Cystectomy: Experience with a Modification of the Studer Pouch

Bladder substitution using pouches designed from detubularized bowel is gaining widespread acceptance among urologists and their patients. However, few clinical reports have described the effectiveness of the orthotopic neobladder fashioned from ileum in the manner described by Studer. Since 1988, we have used the Studer technique with minor modifications in 20 men who underwent radical cystoprostatectomy for transitional cell carcinoma of the bladder. Early morbidity from the procedure was minimal, although 2 patients later had anastomotic strictures. Significant late complications included low vitamin B12 levels in 4 patients and persistent hyperchloremia in 1. A total of 18 patients achieved diurnal continence but 9 of these had enuresis. Neobladder compliance and emptying were satisfactory in the 12 patients evaluated urodynamically. Upper tracts remained stable in all patients at a median followup of 24 months (range 9 to 60). Isolated episodes of bacteriuria occurred in 11 patients but followup urine cultures have remained sterile in all continent patients. The Studer ileal neobladder is a simple, effective alternative for urine storage, upper tract preservation and efficient voiding.

Some small prostate cancers are nondiploid by nuclear image analysis: Correlation of deoxyribonucleic acid ploidy status and pathological features

The biological behavior of a prostate cancer can be predicted to some degree by the volume and extent (stage) of the tumor, and its histological grade. The deoxyribonucleic acid (DNA) ploidy status has been reported by some to be another independent prognostic factor for localized prostate cancer. We determined the DNA ploidy value of each individual focus of cancer in radical prostatectomy specimens using nuclear image analysis (CAS 200 system). Ploidy results were correlated with the volume, Gleason grade and zone of origin (transition zone or peripheral zone) of each tumor, and with the presence of extracapsular extension or seminal vesicle invasion. There were 141 separate cancers in 68 patients (mean 2.1 per prostate): 9 clinical stage A1, 22 stage A2, 23 stage B1 and 14 stage B2. DNA ploidy correlated significantly (p < 0.0001) with volume, grade, extraprostatic spread and zone of origin. Remarkably, some small cancers (1 cc or less) were nondiploid (3 as small as 0.03 cc). Overall, 15% of cancers 0.01 to 0.1 cc and 31% of those 0.11 to 1.0 cc in volume were nondiploid. Of 101 cancers confined to the prostate 76% were diploid, compared to only 13% of those with extraprostatic spread. Most cancers of transition zone origin (86%) were diploid, compared to only 49% of peripheral zone cancers, and ploidy and volume relationships were significantly different for peripheral zone cancers compared to transition zone cancers. All small nondiploid cancers arose in the peripheral zone, while in the transition zone the smallest nondiploid cancer was 1.17 cc. We conclude that prostate cancers that are nondiploid are highly likely to have adverse pathological features. Some small prostate cancers contain a nondiploid cell population and these cancers arise predominantly within the peripheral zone of the prostate. Ploidy and volume relationships provide further support for the hypothesis that there is a difference in malignant potential between cancers of peripheral zone and transition zone origin.

Fifteen-year survival and recurrence rates after radiotherapy for localized prostate cancer.

PURPOSEnTo determine 15-year survival and recurrence rates after radiotherapy for localized prostate cancer.nnnMETHODSnOne hundred thirty-six patients with clinically localized prostate cancer treated from 1966 to 1974 with interstitial gold seed and external-beam irradiation were evaluated to determine the probability of recurrence and survival > or = 15 years after therapy. All patients were surgically staged with pelvic lymphadenectomy and none received hormonal therapy before relapse.nnnRESULTSnOverall, 60 patients (44%) have never recurred, although 57% (34 of 60) of these same patients have died of causes other than prostate cancer. Local progression developed in 39% of patients and distant metastases in 42%. At 15 years, the probability of dying of prostate cancer was 33%+/-8% (% +/- 2SE) and of all causes was 72%+/-8%. In clinical stage A2 and B, 29%+/-9% of patients died of their cancer within 15 years, compared with 57%+/-21% in stage C1, while only 18%+/-8% with clinical stage A2 and B and negative lymph nodes died of cancer within this period. In contrast, the prostate cancer mortality rate at 15 years was high for patients with positive nodes regardless of the stage of the primary tumor (73% for A2 and B; 71% for C1). Patients with nodal metastases, poorly differentiated tumors, and advanced local disease all had a significantly (P < .0001) increased risk of cancer death.nnnCONCLUSIONnThe cancer-specific mortality rate for patients with stage A2 and B tumors and negative nodes compares favorably with other series of patients treated with radiation therapy and > or = 15 years follow-up evaluation. While local progression rates are high and associated with a substantial risk of prostate cancer death, many patients live with the disease and ultimately die of causes other than prostate cancer.

Prostate-specific antigen doubling times are similar in patients with recurrence after radical prostatectomy or radiotherapy: a novel analysis.

PURPOSEnSome investigators have analyzed the rate of growth of prostate cancer that has recurred after definitive radiotherapy or radical prostatectomy using serum prostate-specific antigen (PSA) doubling times (DT). We examined all PSA values in recurrent patients to determine the pattern and rate of increase in PSA after radiation therapy and radical prostatectomy.nnnPATIENTS AND METHODSnCharts of 96 recurrent radical prostatectomy patients (mean age, 62.8 years; range, 47 to 76) and 42 recurrent radiation therapy patients (mean age, 67.2 years; range, 52 to 83) were reviewed. All available PSA values between the date of operation/radiation treatment and last follow-up evaluation or the initiation of second-line therapy are included. Rate of PSA DT was not assumed to be constant over time; it was instead allowed to vary. We use a piecewise linear random-coefficients model in time for log (PSA), which allowed different mean models for both treatments.nnnRESULTSnThe PSA DT in the first year after radiation therapy was--1.17 years, which reflects the continuous decline in PSA in the average patients during the first year after radiotherapy despite eventual biochemical progression. In contrast, the PSA DT in the radical prostatectomy group was 0.66 in the first year. In year 2, after radiation therapy, the PSA DT was lengthy at 1.82 years, significantly longer (P = .0025) than in the radical prostatectomy group (0.76 years). After year 2, there were no significant differences between the two groups (P > .05).nnnCONCLUSIONnA piecewise linear random-coefficients model enables interval analysis of PSA DT. While the PSA DT after radiation therapy and radical prostatectomy are different in the first 2 years, the rate of increase in PSA appears to be similar in the two groups after year 2, which suggests the rate of growth of cancers that recur after radiation therapy and radical prostatectomy is similar.

PD63-05 BLUNT RENAL TRAUMA: VALIDATION OF A CONSERVATIVE FOLLOW-UP IMAGING STRATEGY

RESULTS: Out of 927 patients who were treated fo renal trauma, 758 had repeat imaging (81.8 %) : 583 (76.9 %) had routine repeat imaging while asymptomatic (SYSTIM), 175 (23,1 %) had repeat imaging due to symptoms (SYMPTIM). The median interval between trauma and repeat imaging was five days if there were no symptoms, and seven days if patients had symptoms. A relevant finding was made more frequently in the SYMPTIM group than in the SYSTIM group (57.1 % vs. 24.1 %, p<0.0001). In thirty patients who had routine repeat imaging (5.1 %), secondary surgery/interventional radiology was needed based on imaging findings, : 19 ureteral stent, 4 percutaneous drainage, 6 embolization and a diaphragmatic tear repair. Initial management was modified in 64 (38.2 %) patients from the SYMPTIM group. There was no significative difference in terms of readmission in the NRIM group vs. the SYSTIM group (2.9 % vs. 3.6 %, p 1⁄4 0.81). CONCLUSIONS: In our study, repeat imaging within 10 days following renal trauma was performed in 81.8% of patients but did change the management in only 5.1% of asymptomatic patients. Repeat imaging after renal trauma could be proposed only to symptomatic patients, with active bleeding or urinary extravasation on the initial CT and patients at risk of renal pseudo-aneurysm.