Predictors of symptomatic lymphocele after radical prostatectomy and bilateral pelvic lymph node dissection.

OBJECTIVES: Lymphocele is the most common complication of pelvic lymphadenectomy (PLND). We sought to determine predictors of symptomatic lymphocele after radical prostatectomy (RP) and PLND, and in particular, to determine if the number of drains placed represents an independent predictor. METHODS: Between January 1999 and June 2007, 4173 consecutive patients underwent bilateral PLND at the time of either open or laparoscopic RP. Lymphoceles were identified in patients undergoing imaging as a result of symptoms suspicious for lymphocele, such as fever, abdominal pain or lower extremity swelling. Routine postoperative imaging was not carried out. Cox proportional hazards analysis was carried out using forced variable entry to obtain maximum likelihood estimates of the hazard ratios and 95% confidence intervals using the number of drains placed, number of nodes removed, RP approach and use of prophylactic low-molecular-weight heparin (LMWH) as predictors of symptomatic lymphocele. RESULTS: There were 164 patients (4%) with a symptomatic lymphocele on follow up, with a median time to presentation of 19 days. The primary presenting complaints were fever in 47%, abdominal pain in 40%, lower extremity swelling in 37%, genital swelling in 25%, groin pain in 22%, abdominal swelling in 9%, and back and flank pain in 6% and 5%, respectively. Median lymphocele diameter was 5 cm. Significant predictors of symptomatic lymphocele on multivariate analysis included number of nodes removed and use of LMWH, but not number of drains placed. CONCLUSIONS: Use of prophylactic LMWH and a higher node count are predictive of a higher incidence of symptomatic lymphocele after RP and PLND.

Impact of prior prostate radiation on complications after radical prostatectomy.

PURPOSE: Salvage radical prostatectomy is associated with a higher complication rate than radical prostatectomy without prior radiotherapy but the magnitude of the increase is not well delineated. MATERIALS AND METHODS: A total of 3,458 consecutive patients underwent open radical prostatectomy and 98 underwent open salvage radical prostatectomy from January 1999 to June 2007. Data were collected from prospective surgical and institutional morbidity databases, and retrospectively from billing records and medical records. Medical and surgical complications were captured, graded by the modified Clavien classification and classified by time of onset. RESULTS: Median followup after salvage radical prostatectomy and radical prostatectomy was 34.5 and 45.5 months, respectively. Patients with salvage had significantly higher median age, modified Charlson comorbidity score, clinical and pathological stage, and Gleason score. They were less likely to have organ confined disease and more likely to have seminal vesicle invasion and nodal metastasis. There was no significant difference in median operative time, blood loss or transfusion rate. The salvage group had a higher adjusted probability of medical and surgical complications, including urinary tract infection, bladder neck contracture, urinary retention, urinary fistula, abscess and rectal injury. Only 1 of 4 potent patients with salvage prostatectomy who underwent bilateral nerve sparing recovered erection adequate for intercourse. The 3-year actuarial recovery of continence was 30% (95% CI 19-41). CONCLUSIONS: Medical and surgical complications of prostatectomy are significantly increased in the setting of prior radiotherapy. Understanding the magnitude of this increased risk is important for patient counseling.

The depth of the prostatic apex is an independent predictor of positive apical margins at radical prostatectomy.

OBJECTIVE: To determine the effect of a deep and narrow pelvis on apical positive surgical margins (PSM) at radical prostatectomy (RP), controlling for other clinical and pathological variables and surgical approach, i.e. open retropubic (RRP) vs laparoscopic (LRP), as apical dissection is expected to be more challenging at RP with a prostate situated deep in a narrow pelvis. PATIENTS AND METHODS: From July 2003 to January 2005, 512 consecutive patients with preoperative prostate magnetic resonance imaging (MRI) underwent RRP or LRP with no previous radio- or hormonal therapy. An additional 74 patients with preoperative MRI undergoing RP from December 2001 to June 2007 who had an apical PSM were also included, with 586 patients comprising the study population. Bony and soft-tissue pelvic dimensions, including interspinous distance (ISD), bony (BFW) and soft tissue (SW) pelvic width, apical prostate depth (AD) and symphysis pubis angle, were measured on preoperative MRI. The pelvic dimension index (PDI), bony width index (BWI) and soft-tissue width index (SWI) were defined as ISD/AD, BFW/AD and SW/AD, respectively. Multivariate logistic regression was used to assess the effect of pelvic dimensions on apical PSM, controlling for surgical approach and clinical and pathological variables. RESULTS: There was no significant difference in ISD, BFW, SW or symphysis angle between patients with and without apical PSM. The AD was significantly greater in men with an apical PSM and consequently PDI, BWI and SWI were significantly lower in men with an apical PSM. Each of PDI, AD, BWI and SWI was a significant independent predictor of apical PSM, independent of surgical approach, and other clinicopathological variables. The main limitations of the study were that it was retrospective, and the relatively few patients with apical PSM. CONCLUSIONS: Apical prostate depth is an independent risk factor for apical PSM at RP. MRI pelvimetry might allow for preoperative planning of the approach to RP.

Time course of recovery of erectile function after radical retropubic prostatectomy: does anyone recover after 2 years?

INTRODUCTION: Given the paucity of literature on the time course of recovery of erectile function (EF) after radical prostatectomy (RP), many publications have led patients and clinicians to believe that erections are unlikely to recover beyond 2 years after RP. AIMS: We sought to determine the time course of recovery of EF beyond 2 years after bilateral nerve sparing (BNS) RP and to determine factors predictive of continued improved recovery beyond 2 years. METHODS: EF was assessed prospectively on a 5-point scale: (i) full erections; (ii) diminished erections routinely sufficient for intercourse; (iii) partial erections occasionally satisfactory for intercourse; (iv) partial erections unsatisfactory for intercourse; and (v) no erections. From 01/1999 to 01/2007, 136 preoperatively potent (levels 1-2) men who underwent BNS RP without prior treatment and who had not recovered consistently functional erections (levels 1-2) at 24 months had further follow-up regarding EF. Median follow-up after the 2-year visit was 36.0 months. MAIN OUTCOME MEASURES: Recovery of improved erections at a later date: recovery of EF level 1-2 in those with level 3 EF at 2 years and recovery of EF level 1-3 in those with level 4-5 EF at 2 years. RESULTS: The actuarial rates of further improved recovery of EF to level 1-2 in those with level 3 EF at 2 years and to level 1-3 in those with level 4-5 EF at 2 years were 8%, 20%, and 23% at 3, 4, and 5 years postoperatively, and 5%, 17%, and 21% at 3, 4, and 5 years postoperatively, respectively. Younger age was predictive of greater likelihood of recovery beyond 2 years. CONCLUSION: There is continued improvement in EF beyond 2 years after BNS RP. Discussion of this prolonged time course of recovery may allow patients to have a more realistic expectation.

Impact of ethnicity on surgical margins at radical prostatectomy.

OBJECTIVE: To determine if the rate of positive surgical margins (PSMs), and in particular apical PSMs, at radical prostatectomy (RP) for prostate cancer, is higher in African-American (AA) than Caucasian men, given their often narrower and deeper pelvis. PATIENTS AND METHODS: From 1999 to 2007, 3145 consecutive patients underwent RP, either open retropubic (RRP) or laparoscopic (LRP), with no previous treatment, by one of five surgeons. Multivariate logistic regression was used to determine the effect of ethnicity (AA vs Caucasian) on overall and site-specific PSMs, adjusting for age, body mass index, RP approach (RRP vs LRP), surgeon, surgeon case number, year of surgery, preoperative serum prostate-specific antigen level, specimen weight, estimated blood loss, pathological organ-confined status, and pathological Gleason score. RESULTS: In all, 205 men were AA and 2940 Caucasian; PSMs were identified in 376 (12.0%) men, 35 (17.1%) in AA and 341 (11.6%) in Caucasian men. PSMs were identified at the apex in 148 (4.7%), the bladder neck in 29 (0.9%), posteriorly in 169 (5.4%), and anteriorly in 78 (2.5%) men. For apical PSM, ethnicity was a significant predictor, with an odds ratio of 1.76 (95% confidence interval 1.01-3.04, P = 0.045) for AA vs Caucasian, independent of pathological organ-confined status and PSA level. Ethnicity was not a significant independent predictor of overall PSMs or PSMs at other sites (bladder neck, posteriorly, or anteriorly). CONCLUSIONS: The rate of apical PSMs, but not overall PSMs, at RP was higher in AA than Caucasian men, controlling for other covariates. Further investigation is necessary to determine if pelvic shape is responsible for this observation.

Biochemical recurrence rate in patients with positive surgical margins at radical prostatectomy with further negative resected tissue.

OBJECTIVE: To determine the biochemical recurrence (BCR) rate in patients with positive surgical margins (PSMs) on the prostate specimen who have additional negative tissue resected from that site (M+ -), compared to patients with negative margins (M-) and those with persistent PSM (M+), as those with PSM at radical prostatectomy (RP) are at greater risk of BCR, and in some instances where suspicious tissue is noted in the prostate bed or when frozen-section analysis shows PSM, additional tissue is resected from the suspect site of the PSM. PATIENTS AND METHODS: Between January 1999 and June 2007, 4217 consecutive patients underwent open or laparoscopic RP with no previous radiotherapy or hormonal therapy. The median (interquartile range) follow-up was 37.4 (21.1-60.7) months. RESULTS: Pathological organ-confined (OC) cancer was present in 2901 men, of whom 2659 had M-, 216 had M+, and 26 had M+-. Extracapsular extension (ECE) alone with no seminal vesicle or lymph node involvement was present in 843 men, of whom 657 had M-, 174 had M+ and 12 had M+-. For patients with OC cancer, the 36-month actuarial BCR-free probability was 97.9% (95% confidence interval 97.3-98.5) for M-, vs 89.0 (84.1-93.9)% for M+ vs 100% for M+-. For patients with ECE, the 36-month actuarial BCR-free probability was 83.7 (80.0-87.4)% for M- vs 73.7 (66.1-81.3)% for M+ vs 90.0 (71.4-100)% for M+-. The main limitation of the study was its retrospective nature, with the reason for resection of additional tissue not always well documented. CONCLUSIONS: While the few patients with PSMs and further negative resected tissue limited the statistical analysis, it would appear that in these patients the disease behaves as in those with negative margins.

Predictors of inguinal hernia after radical prostatectomy.

OBJECTIVES: To determine the significant independent predictors of inguinal hernia development after radical prostatectomy (RP) so that prophylactic measures can be undertaken in those at increased risk. Although inguinal hernia is a recognized complication after RP, the risk factors have not been well elucidated. METHODS: From January 1999 to June 2007, 4592 consecutive patients underwent open retropubic RP or laparoscopic RP without previous radiotherapy. The median follow-up was 36.9 months (interquartile range 20.3, 60.6). Comorbidities were recorded, as well as the occurrence of inguinal hernia, wound infection, and bladder neck contracture. Cox proportional hazards analysis was performed for the predictors of inguinal hernia after RP on multivariate analysis. RESULTS: Inguinal hernia developed after RP in 68 men (1.5%) men at a median follow-up of 7.9 months (interquartile range 4.3, 18.1). The laterality was bilateral in 7, right in 27, left in 24, and not documented in 10 patients. The significant independent predictors of inguinal hernia included age (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.01-1.09, P = .016), body mass index (HR 0.91, 95% CI 0.85-0.98, P = .011), history of inguinal hernia repair (HR 3.9, 95% CI 1.8-8.2, P <.001), and bladder neck contracture (HR 2.8, 95% CI 1.3-5.9, P = .007) but not the RP approach (HR 1.08, 95% CI 0.60-1.96, P = .80 for laparoscopic RP vs retropubic RP). CONCLUSIONS: The results of our study have indicated that older patients, thinner patients, those with previous inguinal hernia repair, and those developing bladder neck contracture are at increased risk of developing an inguinal hernia. These factors might identify a subset for whom evaluation for subclinical hernia might allow prophylactic inguinal hernia repair at RP.

Ethnic variation in pelvimetric measures and its impact on positive surgical margins at radical prostatectomy.

OBJECTIVES: We sought to evaluate the ethnic variation in pelvimetry and its impact as a predictor of positive surgical margins (PSM) at radical prostatectomy (RP). METHODS: Preoperative MRI was performed in 482 Caucasian and 103 African American (AA) men undergoing RP without previous treatment from July 2003 to January 2005 and November 2001 to June 2007, respectively. We measured bony and soft tissue dimensions on magnetic resonance imaging (MRI) to evaluate the pelvic inlet, midplane, prostate size, and apical depth. Analysis of covariance was performed to determine the effect of ethnicity on the midpelvic area (MPA). We performed multivariate logistic regression analysis for prediction of overall and site-specific PSM. RESULTS: AA men had a significantly steeper symphysis pubis angle (median, 43.1 vs. 41.3°, respectively, P = .001) and smaller MPA (median, 78.5 vs. 83.9 cm(2), respectively, P = .004). Ethnicity and BMI were found to have a significant effect on MPA. Apical depth of the prostate was identified as a significant independent predictor of apical PSM, with a more pronounced effect in AA men. Pelvimetric measures were not a significant predictor of other sites of PSM. CONCLUSIONS: AA men have a significantly smaller MPA and steeper symphysis angle. The adverse impact of a deep pelvis, as measured by the apical prostatic depth on apical PSM was found to be greater in AA men. Evaluation of pelvic dimensions and prostate parameters in preoperative MRI may add to our understanding of their impact on surgical outcomes.

Comprehensive standardized report of complications of retropubic and laparoscopic radical prostatectomy.

BACKGROUND: The lack of standardized reporting of the complications of radical prostatectomy in the literature has made it difficult to compare incidences across institutions and across different surgical approaches. OBJECTIVE: To define comprehensively the incidence, severity, and timing of onset of medical and surgical complications of open retropubic prostatectomy (RP) and laparoscopic radical prostatectomy (LP) using a standardized reporting methodology to facilitate comparison. DESIGN, SETTING, AND PARTICIPANTS: Between January 1999 and June 2007, 4592 consecutive patients underwent RP or LP without prior radiation or hormonal therapy. Median follow-up was 36.9 mo (interquartile range: 20.3-60.6). INTERVENTION: Open or laparoscopic radical prostatectomy. MEASUREMENTS: All medical and surgical complications of radical prostatectomy were captured and graded according to the modified Clavien classification and classified by timing of onset. RESULTS AND LIMITATIONS: There were 612 medical complications in 467 patients (10.2%) and 1426 surgical complications in 925 patients (20.1%). The overall incidences of early minor and major medical and surgical complications for RP were 8.5% and 1.5% for medical and 11.4% and 4.9% for surgical complications, respectively. The overall incidences of early minor and major medical and surgical complications for LP were 14.2% and 2.3% for medical and 23.1% and 6.6% for surgical complications, respectively. On multivariate analysis, LP approach was associated with a higher incidence of any grade medical and surgical complications but a lower incidence of major surgical complications than RP. Six hundred fifty-two men (14.2%) visited the emergency department, and 240 men (5.2%) required readmission. The main limitation is the retrospective nature. CONCLUSIONS: With standardized reporting, the incidence of some complications is higher than recognized in the literature. Although most complications are minor in severity, medical and surgical complications are observed in approximately 10% and 20% of patients, respectively. Accurate reporting of complications through a standardized methodology is essential for counseling patients regarding risk of complications, for identifying modifiable risk factors, and for facilitating comparison across institutions and approaches.