Achieving optimal outcomes after radical prostatectomy.

PURPOSE: The most favorable outcome that can be achieved after radical prostatectomy is complete tumor resection without recurrence and full recovery of continence and potency. Risks of erectile dysfunction, incontinence, and disease recurrence are well described, but in isolation, do not adequately inform patients of the possibility of becoming cancer-free while at the same time returning to their preoperative functional state. We sought to determine the frequency of optimal outcomes after radical prostatectomy and the time to such outcomes. PATIENTS AND METHODS: Patients who underwent radical prostatectomy performed at a tertiary referral center between July 1998 and July 2003 for clinical stage T1 to T3 prostate cancer were identified. Patients were excluded if they were incontinent or impotent preoperatively, or if they had received radiotherapy or neoadjuvant androgen deprivation therapy previously. Six hundred forty-seven patients were analyzed for time to recovery of full continence and potency without cancer recurrence after surgery. Optimal outcome probability was calculated with a Markov state transition model to simulate clinical outcomes in the first 4 years following radical prostatectomy. RESULTS: Mean patient age was 58 years, and mean pretreatment prostate-specific antigen was 6.9 ng/mL. Cancer-free status with full continence and potency was achieved in 30% of men at 12 months, 42% at 24 months, 47% at 36 months, and 53% at 48 months postoperatively. CONCLUSION: Optimal outcomes after radical prostatectomy can be achieved in a small majority of cases. Time to full recovery is primarily dictated by recovery of erectile function. This information is helpful for patients interested in their chances of returning to their preoperative functional state.

Laparoscopic radical prostatectomy.

Laparoscopic radical prostatectomy is a relatively new approach to the surgical treatment of localized prostate cancer. Since its inception, the technique, however challenging, is undergoing continuous refinements which make it today a feasible, reproducible, and teachable operation practiced by urologists worldwide. The advantages of the laparoscopic approach are a magnified view of the anatomic structures, and a decreased venous bleeding in the surgical field allowing an accurate dissection of the prostate and neurovascular bundles. These advantages translate to a low positive surgical margin rate, low morbidity profile, and favorable postoperative quality of life outcomes. However, since the technique has only been performed for the past 6 years, long term cancer control and functional results data following laparoscopic radical prostatectomy are not available. For a successful laparoscopic prostatectomy program, advanced laparoscopic skills, knowledge of the prostatic anatomy, and expertise in surgical oncology are required.

Anatomy of accessory pudendal arteries in laparoscopic radical prostatectomy.

PURPOSE: The incidence of accessory pudendal arteries (APAs) varies from 4% to 70% depending on the means used to identify them. We provide a detailed laparoscopic anatomical description of their appearance, location and identification rate based on our series of radical prostatectomies. MATERIALS AND METHODS: The distribution of APAs was prospectively recorded in 285 consecutive patients between October 2002 and November 2004. We defined an APA as any artery located within the periprostatic region running parallel to the dorsal vascular complex and extending caudal toward the anterior perineum, other than cavernous arteries, corona mortis and satellite arteries to the superficial and deep vascular complex. RESULTS: We identified 92 APAs in 72 of 285 patients (25%). Two distinct varieties of APAs were identified. In 10% of patients an APA coursed along the lateral aspect of the prostate, termed lateral APA, and in 13% an APA emerged through the levator ani fibers near the apical region of the prostate, termed apical APA. Five patients (1.7%) were found to have apical and lateral APAs. CONCLUSIONS: APAs are more frequent than previously reported in the surgical literature. To our knowledge apical APAs have never been reported previously. The visualization and accessibility advantages of laparoscopy may account for a higher intraoperative APA identification rate. Their roles in continence and potency remain to be determined.

Role of voided urine cytology in diagnosing primary urethral carcinoma.

OBJECTIVES: To evaluate the role of voided urine cytology in diagnosing primary carcinoma of the urethra in male and female patients. METHODS: We reviewed the medical records of all patients with urethral carcinoma seen at Memorial Sloan-Kettering Cancer Center between 1958 and 1996. The patients who had undergone voided urine cytology before any treatment were the subject of this report. RESULTS: This report included 41 female and 29 male patients. In the cohort of female patients, the most common histologic type was adenocarcinoma (n = 16), followed by squamous cell carcinoma (SCC; n = 9) and transitional cell carcinoma (TCC; n = 6). Urine cytology was positive in 24 patients (59%). The sensitivity was greatest in patients with SCC (77%) and lowest in patients with TCC (50%). In the cohort of male patients, the most common histologic type was SCC (n = 14) followed by TCC (n = 10). Urine cytology was positive in 16 patients (55%). The sensitivity was greatest for patients with TCC (80%) and lowest for patients with SCC (50%). CONCLUSIONS: Voided urine cytology is not a very reliable method of diagnosing primary carcinoma of the urethra in either male or female patients. A cystoscopic evaluation with possible biopsy is warranted if suspicion of carcinoma of the urethra is high.

Partial nephrectomy for patients with a solitary kidney: the Memorial Sloan-Kettering experience.

OBJECTIVE: To report the experience of partial nephrectomy in patients with a solitary kidney at one institution, with analysis of renal function, complications, oncological efficacy and survival. PATIENTS AND METHODS: We identified 54 consecutive patients with a solitary kidney who had a partial nephrectomy between December 1989 and July 2003. Variables examined included patient age and gender, renal function, renal ischaemia time, surgical margin status and complications. Pathological features, e.g. tumour size, histological subtype and tumour stage, were also assessed. Disease-free probability and overall and cancer-specific survivals were determined. RESULTS: The histological subtype was clear cell in 35 cases (65%), papillary in 10 (19%), oncocytoma in four (7%), chromophobe in two (4%), unclassified in one (2%) and multiple subtypes in two (2%). The median creatinine level before surgery was 14 mg/L, which increased to 16 mg/L 6 months afterward, and at 1 and 2 years after surgery it was 15 mg/L. Two patients developed end-stage renal disease requiring haemodialysis, one soon after surgery and another 8 years after nephron-sparing surgery. In all, 26% of patients developed at least one perioperative complication, with acute renal failure and urinary fistula being the most common. At 5 years the overall and cancer-specific survival, and disease-free probability were 68%, 88% and 73%, respectively. CONCLUSIONS: Partial nephrectomy is safe in patients with a solitary kidney, with an acceptable decline in renal function and low likelihood of requiring temporary or permanent haemodialysis. After an initial decline, renal function appears to stabilize during the first year.

Multi-institutional long-term experience with conservative surgery for invasive penile carcinoma.

PURPOSE: Invasive squamous cell carcinoma of the penis occurs on the glans, prepuce, glans and prepuce, coronal sulcus and shaft. Penile squamous cell carcinoma subsequently invades local structures, corpora cavernosa and the urethra, and metastasizes to the inguinal lymph nodes. Invasive squamous cell carcinoma of the penis usually requires total or partial penectomy. We studied the effect of primary tumor resections tailored to the anatomical extent of the cancer with preservation of uninvolved structures in select patients with invasive penile squamous cell carcinoma. MATERIALS AND METHODS: A total of 30 patients between 39 and 82 years old were treated with unconventional conservative surgical excision of the primary penile lesion. More than 130 patients were excluded from the study because they were treated with partial or total penectomy, Mohs' surgery or more extensive surgery. The 30 patients underwent preoperative biopsy with careful mapping of the extent of the disease. Patient age, tumor extent and grade, operative details, outcome and length of followup were analyzed. RESULTS: Tumor size ranged from 1.5 to 8 cm. in diameter. Tumors were well differentiated in 19 patients, moderately differentiated in 5 and poorly differentiated in 6. A total of 17 patients underwent ilioinguinal lymphadenectomy, 12 of whom had pathologically positive lymph nodes. Inguinal radiation was used in 2 patients. Chemotherapy was given to 7 patients with extensive inguinal lymphadenopathy and to 2 of 5 with pathologically positive lymph nodes. Followup ranged from 12 to 360 months. A total of 21 patients had no evidence of disease at last followup. Tumor resection with no sacrifice of function was performed in 2 patients in whom 3 small recurrences developed. One patient with numerous tumors had 2 small recurrences, which were completely excised with no further recurrence. Of the 7 patients with advanced lymphadenopathy 5 and of 5 patients with pathologically positive lymph nodes at presentation 1 died of the cancer but had no local recurrence in the penis. CONCLUSIONS: In a minority of patients with anatomically suitable penile cancer conservative surgical techniques are safe and provide equal tumor control compared to conventional resections. The anatomical situation and tumor characteristics should dictate the choice of treatment for the primary penile lesion. Inguinal lymph nodes should be managed by appropriately established guidelines but should not influence the extent of primary penile lesion resection.