Roy J. Correa

Prostate Cancer Clinical Guidelines Panel Summary Report on the Management of Clinically Localized Prostate Cancer

PURPOSE The American Urological Association convened the Prostate Cancer Clinical Guidelines Panel to analyze the literature regarding available methods for treating locally confined prostate cancer, and to make practice policy recommendations based on the treatment outcomes data insofar as the data permit. MATERIALS AND METHODS The panel searched the MEDLINE data base for all articles from 1966 to 1993 on stage T2 (B) prostate cancer and systematically analyzed outcomes data for radical prostatectomy, radiation therapy and surveillance as treatment alternatives. Outcomes considered most important were survival at 5, 10 and 15 years, progression at 5, 10 and 15 years, and treatment complications. RESULTS The panel found the outcomes data inadequate for valid comparisons of treatments. Differences were too great among treatment series with regard to such significant characteristics as age, tumor grade and pelvic lymph node status. The panel elected to display, in tabular form and graphically, the ranges in outcomes data reported for each treatment alternative. CONCLUSIONS In making its recommendations, the panel presented treatment alternatives as options, identifying the advantages and disadvantages of each, and recommended as a standard that patients with newly diagnosed, clinically localized prostate cancer should be informed of all commonly accepted treatment options.

Adjuvant Radiotherapy Following Radical Prostatectomy: Results and Complications

Between 1954 and 1978, 148 patients underwent radical perineal prostatectomy for adenocarcinoma clinically confined to the prostate gland. This report is based on 45 of these patients with microscopic extension of disease beyond the gland and a minimum 5-year followup. Of the patients 22 received adjuvant external beam radiation therapy and 23 did not. The groups were comparable with regard to significant prognostic variables. Patient selection was by surgeon preference. Local recurrences were seen in 1 of 22 patients (5 per cent) receiving adjuvant radiotherapy and 7 of 23 (30 per cent) undergoing an operation alone (p less than 0.05). Of 8 patients with local recurrence 7 died of the disease. Delayed radiotherapy of a local recurrence generally was not effective in controlling the disease. Of the 11 patients who died of prostatic cancer with a mean followup of 9.2 years 3 received adjuvant radiotherapy and 8 did not. Severe but nonfatal long-term complications were seen in 14 per cent of the irradiated patients and 6 per cent of those treated with an operation alone. Most of the complications occurred in the earlier years of the study in patients who received 60cobalt radiotherapy. When clinical stage B cancer of the prostate is found to be pathological stage C following radical perineal prostatectomy, adjuvant radiotherapy can decrease the incidence of subsequent local recurrence. The potential risk of adjuvant radiation therapy should be weighed and its use considered, particularly in patients whose tumor extends to the surgical margins or who have seminal vesicle invasion.

Kidney Stone Removal: Percutaneous Versus Surgical Lithotomy

Percutaneous removal of most urinary tract calculi may be performed as a 1-stage effort with techniques and skills developed recently in the specialties of urology and radiology. Ultrasonic fragmentation of most calculi was done to permit their extraction. Percutaneous ultrasonic lithotripsy was performed on 250 consecutive (a single exception) patients bearing stones that required removal. Targeted calculi were removed successfully from 97 per cent of these patients. One patient required surgical lithotomy. The previous 100 patients with stones underwent surgical lithotomy with 96 per cent success. Complications of percutaneous ultrasonic lithotripsy appeared equitable with those of surgical lithotomy. Of the patients who underwent percutaneous ultrasonic lithotripsy 6 (6 per cent) required extended hospital days or additional procedures for management of complications. None of these patients required a surgical incision. Anesthesia times were similar for both groups--average 159 plus or minus 4 (standard error) minutes for percutaneous ultrasonic lithotripsy and 193 plus or minus 8 minutes for surgical lithotomy. Hospital recovery days averaged 5.5 plus or minus 0.3 for percutaneous ultrasonic lithotripsy and 8.4 plus or minus 0.5 for surgical lithotomy (p less than 0.01). Associated costs averaged

Total Prostatectomy for Clinically Localized Prostatic Cancer: Long-term Results

7,203 plus or minus 55 for lithotripsy and

Endopyelotomy: Review of Results and Complications

8,849 plus or minus 660 for lithotomy (p less than 0.01). The number of narcotic administrations per patient (days 1 to 5 postoperatively) averaged 9.88 plus or minus 0.70 for lithotripsy and 16.82 plus or minus 0.78 for lithotomy (p less than 0.01). The average patient who underwent percutaneous ultrasonic lithotripsy felt capable of full activity 2.0 plus or minus 0.2 weeks following stone removal, whereas no patient who underwent previous surgical lithotomy recalls a recovery period of less than 3 weeks (p less than 0.01). We believe that most upper urinary tract calculi may be removed cost-effectively with a percutaneous approach. Compared to surgical lithotomy, percutaneous ultrasonic lithotripsy may result in rapid convalescence with diminished pain.

A nomogram predicting long-term biochemical recurrence after radical prostatectomy

The fate of the first 52 patients with clinically localized prostate cancer who underwent total perineal prostatectomy at our clinic and have been followed for a minimum of 15 years is reviewed to evaluate the long-term impact of this operation on the disease. None of these patients received any adjuvant therapy. Nine patients (17 per cent) had recurrence and 5 (10 per cent) died of disease during this interval. The actual observed over-all survival at 15 years was 64 per cent, the actuarial survival was 67 per cent and the cause-specific survival was 90 per cent.

Mechanical reliability, surgical complications, and patient and partner satisfaction of the modern three-piece inflatable penile prosthesis

Percutaneous endopyelotomy augmented by balloon dilation was performed on 27 of 40 patients for the treatment of symptomatic, primary ureteropelvic junction obstruction. Percutaneous ultrasonic lithotripsy was performed simultaneously on 12 of 27 patients (44%) for associated calculi. After endopyelotomy 24 of 27 patients became asymptomatic (clinical success rate 89%). Three clinically improved patients demonstrated only radiographic stability, while radiographic improvement was documented in 21 of 27 (radiographic success rate 78%). Adjuvant percutaneous ultrasonic lithotripsy was successful from the standpoint of stone removal in all patients and no increased morbidity could be identified. Of 27 patients 3 (11%) suffered major complications and are considered failures. Reasons for failure varied and are discussed. Included is a patient who at nephrostography and stent capping became septic and subsequently died. To decrease the risk of sepsis perioperative antibiotics to include at the time of nephrostomy tube capping are recommended. Angiography was performed in 19 of 40 patients to rule out an accessory crossing vessel at the ureteropelvic junction, and such a vessel was found in 6. From analysis of presenting excretory urograms (IVPs) we conclude that a crossing vessel cannot predictably be identified on an IVP.

Pubovaginal Slings Using Fascia Lata for the Treatment of Intrinsic Sphincter Deficiency

Men who undergo radical prostatectomy (RP) are at long‐term risk of biochemical recurrence (BCR). In this report, the authors have described a model capable of predicting BCR up to at least 15 years after RP that can adjust predictions according to the disease‐free interval.

Carcinoma of the prostate: local control with external beam radiation therapy.

OBJECTIVES The modern three-piece inflatable penile prosthesis (IPP) has undergone multiple revisions since its introduction in 1973. We reviewed devices placed since the last major revision by American Medical Systems (AMS) in 1987. METHODS A retrospective chart review was refined with data from an independent patient and partner survey. RESULTS Two hundred twelve consecutive penile prosthetic devices placed by a single surgeon over an 8-year period are reviewed. One hundred sixty-nine of the devices were three-piece inflatables with 146 being primary implants. The average device has been in place 36.5 months (range 9 to 102). The infection rate in 146 primary three-piece devices was 2.1%. The infection rate in 46 secondary implants or revisions was 6.5%, excluding seven salvage attempts. Mechanical failure in 122 primary AMS devices placed was 4.1%. Mechanical failure in 24 Mentor devices was 4.2% if one discounts connector failures that were revised in 1990. A surgical complication and revision rate of 1.4% was noted in the 146 primary implants. An independent telephone survey achieved a 57% and 24% response rate in patients and partners with three-piece devices placed. In the group of 86 patients with a primary three-piece device placed and complete follow-up, the probability of having a normally functioning device placed in a single operative procedure was 90.6% at 3 years. On a 1 to 10 scale looking at all primary devices, secondary devices, revisions, and infections, the average and median satisfaction rate was as follows: 8.2, 8.5; 8.4, 9.0; 7.7, 7.75 for the Ultrex patients, CX 700 and Mentor patients, and all partners, respectively. CONCLUSIONS The modern three-piece IPP is an excellent surgical option offering a very safe, reliable return to sexual activity for our patients.

Total prostatectomy for stage B carcinoma of the prostate.

PURPOSE Various materials and techniques have been used to construct a pubovaginal sling. We believe that fascia lata has several advantages and report our experience. MATERIALS AND METHODS A total of 32 female patients with urodynamically proved intrinsic sphincter deficiency underwent a pubovaginal sling procedure using fascia lata. An unscarred fascial strip 24 to 28 x 2 cm. was attached to itself over a 3 to 4 cm. bridge of abdominal wall fascia. Results were tabulated by chart review and an independent patient survey. RESULTS Chart review revealed that 28 of 32 patients (87%) required no pads, and 3 improved and 1 did not. An independent patient survey revealed that 70% of patients (21 of 30) required no pads, 20% required 1 to 3 small pads and 10% required more than 3 small pads per day. Of the patients 80% would undergo the procedure again. CONCLUSIONS Excellent results can be obtained with fascia lata for the treatment of intrinsic sphincter deficiency. A long, wide strip of fascia attached to itself allows for precise tensioning and good urethral closure, and minimizes the risk of obstruction.