Matthew D. Young

Prospective evaluation of pain medication requirements and recovery after radical perineal prostatectomy

OBJECTIVES To perform a study to quantify the variables relating to postoperative pain, activity, and gastrointestinal function after radical perineal prostatectomy to allow comparisons with alternative treatments. METHODS Ninety-eight consecutive radical perineal prostatectomy candidates between January 2001 and December 2001 with clinically localized prostate cancer were prospectively evaluated. The time to tolerate solid food, time to unassisted ambulation, postoperative pain levels (analog pain scale of 1 to 10), and perioperative analgesic requirements (in morphine equivalents) were selected as the analysis endpoints and correlated with preoperative (age, American Society of Anesthesiology class, body mass index, and serum prostate-specific antigen level), intraoperative (node dissection, operating room time, and estimated blood loss), and postoperative (Gleason score, tumor stage, and lower extremity neurapraxia) patient variables. RESULTS The mean time to tolerate solid food and unassisted ambulation was 21.2 +/- 1.4 and 22.4 +/- 0.8 hours, respectively; 25.5% of patients experienced transient lower extremity neurapraxia, which was associated with longer operative times (P = 0.001). In a multivariate regression analysis, lymph node dissection correlated with both a prolonged time to tolerate solid food (P = 0.002) and unassisted ambulation (P = 0.001) and neurapraxia with an extended time to unassisted ambulation (P = 0.018). The narcotic requirements were greatest on postoperative day 1, totaling 31.7 +/- 3.0 morphine equivalents, of which 90.5% +/- 3.1% were met with oral analgesics. The average maximal pain scores were highest the first week after discharge (4.7 +/- 0.3), yet approached baseline levels by 4 weeks (1.7 +/- 0.2) after surgery at which time no patient required any pain medication. CONCLUSIONS Modern radical perineal prostatectomy offers a favorable outcome profile with early patient recovery and low narcotic requirements. A future prospective study should directly compare radical perineal, retropubic, and laparoscopic prostatectomy to document whether the latter offers any advantages with respect to these outcome parameters.

PROSTATIC SARCOMA WITH RAPID TUMOR PROGRESSION AFTER NERVE SPARING RADICAL CYSTOPROSTATECTOMY

Prostate sarcomas are rare but aggressive neoplasms presenting unique therapeutic challenges. We report a case of prostate sarcoma, and discuss disease control and preservation of quality of life. CASE REPORT A 51-year-old healthy male with normal prostate specific antigen was referred to our institution for evaluation of an asymmetrically enlarged nodular prostate and progressive obstructive voiding symptoms. Transrectal ultrasound revealed a multilocular cystic mass replacing the left side of the prostate (fig. 1, A). Pathological examination of the biopsy cores and subsequent chips from transurethral resection of the prostate for acute urinary retention revealed an indeterminate subtype of prostatic sarcoma. Further diagnostic evaluation included pelvic magnetic resonance imaging which demonstrated a complex multilocular solid mass of the left peripheral prostatic lobe displacing the seminal vesicles but without evidence of local invasion (fig. 1, B). Computerized tomography of the chest, abdomen, pelvis and brain, bone scan and fluorodeoxyglucose whole body tumor scan revealed no evidence of metastatic disease. The patient subsequently elected to undergo radical cystoprostatectomy with unilateral sparing of the neurovascular bundle and continent urinary diversion. Pathological examination of the cystoprostatectomy specimen revealed 5 5.5 cm. high grade prostatic sarcoma with focal chondroid differentiation arising from the left prostatic lobe. All surgical margins were negative. The patient presented with bloody urethral discharge 2 months postoperatively. Urethroscopy and biopsy revealed recurrent sarcoma at the level of the external urethral sphincter. Repeat computerized tomography further demonstrated interval development of multiple bilateral pulmonary nodules. The patient was subsequently started on systemic chemotherapy with dacarbazine, ifosfamide, doxorubicin and mesna. DISCUSSION

Ureteral reimplantation for inadvertent ureteral injury during radicalperineal prostatectomy

We report on a rare case of bilateral ureteral injury in a patient undergoing radical perineal prostatectomy and a unique approach to his treatment. Potential risk factors for such an injury include previous prostatic cryotherapy, transurethral resection, or radiotherapy. Intraoperative recognition of the injury is paramount and may be facilitated by intravenous administration of indigo carmine. While distal ureter ligation, urinary diversion, and delayed ureteroneocystostomy may be regarded as standard management for ureteral injury during radical perineal prostatectomy, this case was treated with a primary bilateral transperineal ureteral reimplantation. Although technically challenging, the described case demonstrates the feasibility and success of such an approach.