Have complication rates decreased after treatment for localized prostate cancer?

PURPOSE: The American Urological Association Prostate Cancer Clinical Guidelines Panel reviewed 12,501 publications on prostate cancer from 1955 to 1992 to determine whether the complication rates of external beam radiation therapy, interstitial radiotherapy and radical prostatectomy have decreased. MATERIALS AND METHODS: Complications reported in at least 6 series, study duration and sample sizes were extracted. Year specific study weighted mean patient ages and complication rates were computed. Regression analysis was performed of the study year on weighted mean patient age and complication rate. RESULTS: Study year had a significant effect on mean patient age and rate of the majority of complications examined. Data indicated a gradual increase in study patient age and a simultaneous decrease in complications from 1960 to 1990. CONCLUSIONS: Complication rates in the treatment of localized prostate cancer have decreased during the last 20 to 40 years. This decrease occurred despite evidence that the average age of treated patients had increased during the same period.

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

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.

Extracorporeal shock-wave lithotripsy for bile duct calculi.

BACKGROUND: Bile duct calculi (BDC) can be cleared or treated with modern endoscopic techniques in most patients. However, large stones, bile duct strictures, or unusual anatomy may make endoscopic clearance difficult. The purpose of the present study was to determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in treating patients with complicated BDC. METHODS: Between 1989 and January 1995, 16 patients with BDC were treated at our institution with ESWL using a Dornier HM-3 lithotropter. The average age of patients was 62 years (range 32 to 88). Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and attempted stone extraction (100%), nasobiliary drainage (83%), and biliary stents (6%) were used prior to ESWL. Eleven patients (61 %) had solitary stones, ranging in diameter from 0.5 to 2.6 cm, whereas 7 patients had multiple stones, ranging in diameter from 0.5 to 5.0 cm. The indications for ESWL were stone impaction (56%), stone size (38%), and bile duct stricture (6%). RESULTS: The 16 patients received 27 ESWL treatments (mean = 2101 shock at 21 kV); with 4 patients (22%) requiring multiple treatments. Stone fragmentation was achieved in 94% of patients. All patients had ERCP performed post-ESWL, and only 2 (13%) patients required immediate operations. At discharge, 94% of patients were stone-free. Minor complications (eg, pain, hematuria) were common. With an average follow-up of 3 years, only 1 patient (6%) has required retreatment for BDC. Hepatic transplantation was required in an additional patient. CONCLUSIONS: In this cohort of patients with both major medical comorbidities and/or technical contraindications to standard methods of endoscopic and surgical clearance of BDC, we found that ESWL facilitated stone clearance in 94% of patients with minimal morbidity and no mortality. In our opinion, ESWL should be used more frequently in the treatment of these complex patients.

Extracorporeal shock wave lithotripsy for obstructing pancreatic duct calculi.

PURPOSE: A review was done to determine the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in the treatment of impacted pancreatic duct calculi. MATERIALS AND METHODS: A total of 19 patients, who were potential candidates for radical pancreatic surgery after unsuccessful endoscopic retrograde cholangiopancreatography, sphincterotomy and attempted stone extraction from the pancreatic ducts, underwent ESWL of the calculi. Followup ranged from 6 months to 6 years. RESULTS: Of the 19 patients 14 avoided a major operation and 6 have remained pain-free for the long term. Two patients died of causes not related to ESWL or endoscopic retrograde cholangiopancreatography. Five patients eventually underwent a Whipple or Puestow procedure for relief of symptoms or persistent obstruction. Complications were minimal. CONCLUSIONS: ESWL is a valuable adjunct in patients with impacted pancreatic duct calculi unretrievable by primary endoscopic retrograde cholangiopancreatography.

Pubovaginal slings using fascia lata for the treatment of intrinsic sphincter deficiency.

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.

Prostate Cancer Clinical Guidelines Panel Summary report on the management of clinically localized prostate cancer. The American Urological Association.

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.

Endopyelotomy: review of results and complications.

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.

Is deleting the digital rectal examination a good idea?

Many groups have taken the position that the digital rectal examination should be discontinued as part of the annual screening physical examination. We examined the effects of not doing a digital rectal examination on the early diagnosis of prostate cancer. The average time since a previous rectal examination increased as the stage of cancer increased. The digital rectal examination proved to be a relatively insensitive test, with 40% of stage D cancers being detected initially within 12 months of the most recent examination. Nevertheless, an annual digital rectal examination did detect a greater percentage of lower stage (and thus more localized and potentially curable) cancers when repeated within 12 months. When the last rectal examination was more than 24 months previous, cancers detected were more likely to be advanced. Without a digital rectal examination, patients would have their disease detected only by the presence of symptoms. When it was done because of symptoms, 81% of our patients had stage D cancers compared with 32% of stage B and 38% of stage C patients. Without the routine use of this examination, patients with prostate cancer would be more likely to have higher stage and less potentially curable lesions at the time of diagnosis. We conclude that the digital rectal examination remains an important part of routine annual physical examinations.

Pulsed dye laser fragmentation of ureteral calculi: a review of the first 50 cases performed at Virginia Mason Medical Center.

During the preceding 2 1/2 years 50 patients have undergone laser fragmentation of ureteral calculi at our medical center. Of these 50 patients 48 (96%) became free of stones without the need for an open operation: 44 (88%) were managed in 1 setting and 4 required adjunctive extracorporeal shock wave or ultrasonic lithotripsy, or a repeat session with the laser. Two patients (4%) eventually required an open operation: 1 required ureterolithotomy for a large impacted stone overlying the bony pelvis after a ureteroscope could not be advanced to this level and 1 had a good initial result with the laser but a persistent ureteral stricture developed and he required ureteroureterostomy 4 months later. Both open procedures were necessitated by mid ureteral stones, and the ureteral stricture was believed to be related to ureteroscopy and the impacted nature of the stone, rather than any damage by the laser probe.

Total prostatectomy for clinically localized prostatic cancer: long-term results.

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.

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.

Efficacy of radical prostatectomy for stage A2 carcinoma of the prostate.

Optimal management of men with diffuse incidental prostatic cancer (Stage A2) is an unresolved issue. Current forms of therapy include radical prostatectomy, external beam radiation therapy, and no treatment. Long-term results with curative therapy have been unreported because of the relatively recent substaging of Stage A into incidental and diffuse disease. The results of radical prostatectomy in 25 patients with Stage A2 prostatic cancer were reviewed. Incontinence was the most serious complication and occurred in four patients (16%). Pathologically, 24 patients (96%) had residual carcinoma present in the radical prostatectomy specimen. In 22 men (88%) the tumor was entirely confined to the prostate. Two patients (8%) demonstrated seminal vesicle invasion, and one (4%) had capsular penetration. In follow-up metastatic disease has developed in one patient, and another died without evidence of cancer. The remaining patients are alive without evidence of disease. Since 88% of men with Stage A2 disease have their tumor entirely confined to the prostate, radical prostatectomy offers an excellent chance of long-term cure, as in Stage B prostatic cancer.

Urologic use of gracilis muscle flap for nonhealing perineal wounds and fistulas.

A chronic sinus or urinary fistula in the perineum secondary to surgery and/or radiation therapy for pelvic malignancy may cause serious morbidity and be difficult to treat. The gracilis muscle, either by itself or as a myocutaneous flap, has excellent properties for aiding in healing. Over a six-year period, three nonhealing perineal wounds and three urinary fistulas have healed after the gracilis muscle flap procedure.

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 $7,203 plus or minus 55 for lithotripsy and $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.

Radiation exposure to patient and urologist during percutaneous nephrostolithotomy.

Radiation exposure to the patient and urologist was determined during 60 procedures for percutaneous removal of calculi from the upper collecting system. For male patients the average radiation dose at the surface of the testis was 160 mrem (1.6 mSv.). Surface dose to the female patient at the ovary level averaged 580 mrem (5.8 mSv.). Radiation doses to the small field or region of fluoroscopy on the skin surface anterior to the kidney averaged 25 rem (0.25 Sv.). Radiation exposure to the urologist at collar level averaged 10 mrem (0.1 mSv.) per case. Patient gonad doses from percutaneous nephrostolithotomy are similar to those from a 7-view excretory urogram. Patient surface exposures at the nephrostomy are comparable to skin doses from standard angiographic procedures. The exposure to the urologist is similar to that from other interventional fluoroscopic procedures and is within acceptable limits. Appropriate use of radiological technology and shielding can keep radiation exposures during percutaneous nephrostolithotomy within acceptable limits for patients and physicians.

Morbidity of radical perineal prostatectomy following transurethral resection of the prostate.

Radical prostatectomy in patients who have had prior transurethral resection of the prostate has been reported to result in significant morbidity. From 1974 to 1982, 30 patients who had had previous transurethral resection of the prostate underwent radical perineal prostatectomy for localized prostatic cancer. Operative time and blood loss were similar to a group of patients who had not had prior transurethral resection of the prostate. Over-all, 3 patients (10 per cent) had total incontinence and 3 (10 per cent) had stress incontinence requiring a pad or device. No patient undergoing radical prostatectomy less than 4 weeks or more than 4 months after transurethral resection of the prostate had postoperative incontinence. When radical perineal prostatectomy was performed between 4 weeks and 4 months after transurethral resection of the prostate the incidence of incontinence was 50 per cent. Five patients experienced prolonged perineal urinary drainage, all but 1 of whom healed spontaneously. Of the 6 patients with incontinence 3 had prolonged drainage. No patient had a rectal injury and there was no operative mortality. Two patients died without cancer and 1 has evidence of disease recurrence. We conclude that radical prostatectomy may be performed safely with acceptable morbidity following transurethral resection of the prostate and that if 4 weeks has elapsed since resection it might be advantageous to wait 4 months before performing radical surgery to lessen the risk of incontinence.

Total prostatectomy for localized prostatic cancer.

Several treatment options currently are available for the patient with clinically localized carcinoma of the prostate and each has its proponents. Comparison of results between institutions becomes necessary to determine the relative value of these treatments, keeping in mind the absence of a suitable control group in any series. Such inter-institutional treatment comparisons are possible only if the patient compositions are similar in terms of age, grade and extent of disease. Comparisons of patients with stage B disease frequently are made because most urologists agree that these patients have palpable disease confined to the prostate and no evidence of metastasis. At our clinic willing patients with clinically localized adenocarcinoma of the prostate who have an expected 15-year survival are treated preferentially with total prostatectomy. We summarize our experience with total prostatectomy in 215 consecutive patients, including 213 who were available for followup. There were 16 patients with clinical stage A, 195 with clinical stage B and 2 with clinical stage C disease. Of these patients 207 underwent radical perineal prostatectomy and there were no operative deaths. Patients did not receive adjuvant hormonal therapy unless disease recurred. Of the 110 patients who have undergone the operation within the last 5 years 98 per cent are alive. Actual survival and survival free of disease, respectively, for the entire series were 55 and 48 per cent at 15 years, 75 and 67 per cent at 10 years, and 94 and 86 per cent at 5 years, compared to 55 and 48, 74 and 67, and 95 and 90 per cent, respectively, for the 195 patients with clinical stage B disease. We believe these results demonstrate that in terms of local control of the disease, over-all survival and survival free of disease total prostatectomy remains the optimal treatment for patients with clinically localized carcinoma of the prostate.