Patient-reported impotence and incontinence after nerve-sparing radical prostatectomy.

BACKGROUND: The age-adjusted rate of radical prostatectomy, the most common treatment of early (nonmetastatic) prostate cancer, increased almost sixfold between 1984 and 1990. This increase was due in part to reported improvements in postoperative sexual potency after the use of newly developed "nerve-sparing" procedures. However, published estimates from physicians of impotence following various types of radical prostatectomy may be low, since not all patients may report treatment-related complications accurately and completely to their doctors. In contrast, direct surveys of patients indicate much higher rates of postoperative sexual and urinary dysfunction. One problem with most physician and patient surveys is that they have been performed retrospectively, and pretreatment impotence and incontinence prevalent in older men cannot be assessed accurately in retrospective studies. PURPOSE: This study was initiated in a cohort of men before they underwent radical prostatectomy to assess treatment-related effects on impotence and incontinence. METHODS: The study population consisted of 94 men enrolled in a cohort study of treatment for early prostate cancer. The patients completed questionnaires about sexual and urinary functions before surgery and at 3 and 12 months after surgery and had adequate information to assess the type of surgical technique used (non-nerve-sparing, unilateral nerve-sparing, or bilateral nerve-sparing). Because items assessing sexual function were inadvertently omitted from the questionnaire in the initial months of the study, information on sexual function for all time periods was available for only 49 men. RESULTS: Compared with men who had not been treated with a nerve-sparing procedure, men who underwent nerve-sparing radical prostatectomy, particularly of the bilateral type, were younger and had better prognostic features, indicating less advanced cancers. Before surgery, nine (75%) of 12 men not treated with a nerve-sparing procedure reported erections that were usually inadequate for sexual intercourse compared with six (33%) of 18 men and one (5%) of 19 men who underwent unilateral and bilateral nerve-sparing prostatectomies, respectively. At 12 months after surgery, most men reported inadequate erections, including 15 (79%) of the 19 men who had bilateral nerve-sparing surgery; unilateral nerve preservation provided no apparent benefit. In general, nerve-sparing surgery was associated with more use of absorbent pads at 3 and 12 months following treatment, and this approach was associated with substantial urinary incontinence at 3 months but not at 12 months following surgery. CONCLUSIONS: Nerve-sparing prostatectomy, particularly when performed unilaterally, improves postoperative sexual function to a lesser extent than previously reported. Because men with preoperative impotence and more advanced cancers receive nerve-sparing surgery less often, some of the previously reported benefit of nerve preservation may be the result of patient selection and not of the technique per se.

Adjuvant cyclophosphamide, doxorubicin, and cisplatin chemotherapy for bladder cancer: an update.

Seventy-one patients received adjuvant Cytoxan (cyclophosphamide; Bristol-Myers Co, Evansville, IN), Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH), and cisplatin (CISCA) chemotherapy between March 1981 and March 1986. Patients received adjuvant CISCA chemotherapy if they had pathological findings that were thought to predict for high likelihood of relapse. These included the presence of resected nodal metastases, extravesicular involvement of tumor, lymphatic/vascular permeation of the primary tumor, or pelvic visceral invasion. Sixty-two patients at a similar high risk for recurrence did not receive adjuvant CISCA chemotherapy because they refused, had medical contraindications to therapy, or were not referred for chemotherapy. Two-hundred six patients had a cystectomy performed during the same study period but had none of the poor prognostic features suggesting a high risk for relapse. Sixty-two percent of the patients receiving adjuvant chemotherapy are alive and disease-free for a mean follow-up of 118 weeks (range, 28 to 310 weeks). A survival advantage exists for the adjuvant-treated patients when compared with those with unfavorable pathological findings who did not receive adjuvant chemotherapy (70% v 37%) (P = .00012): no difference exists in long-term disease-free survival for those with favorable pathological findings (long-term disease-free survival 76%) v those who received adjuvant chemotherapy (70%) (P = .33). Adjuvant CISCA chemotherapy prolongs the disease-free survival of some patients following a cystectomy. Patients who benefitted from adjuvant CISCA chemotherapy included those with resected nodal metastases, extra-vesicular involvement of tumor, and direct invasion of the pelvic viscera. Patients not benefitting from adjuvant CISCA chemotherapy in this analysis included those with lymphatic/vascular invasion in their primary tumor as the sole manifestation of high risk for relapse.

Patient-reported symptoms after primary therapy for early prostate cancer: results of a prospective cohort study.

PURPOSE: To assess complications of therapy for early (nonmetastatic) prostate cancer. PATIENTS AND METHODS: A prospective study of a cohort of 279 men who sought treatment advice and completed required pretreatment forms. The measures were self-reported patient symptoms and other measures of quality of life before therapy and at 3 and 12 months afterward. RESULTS: Bowel and bladder symptoms were uncommon pretreatment. Patients frequently reported irritative bowel and bladder symptoms at 3 months after radiotherapy, although these subsided somewhat at 12 months. Substantial ("a lot") urinary incontinence and wearing of absorptive pads were reported by 11% and 35% at 12 months after surgery and varied little by age. Incontinence occurred after radiotherapy infrequently, and only in men more than 65 years old. Inadequate erections, present in one third of men pretreatment, were nearly universal at 3 months after surgery, although some improvement, primarily in men under 65 years of age, was evident at 12 months. Sexual dysfunction after radiotherapy increased less but continually through 12 months, suggesting that observed treatment-related differences would decline with further follow-up. CONCLUSION: External-beam radiotherapy of early prostate cancer is followed by bowel and bladder irritability, by increasingly severe sexual dysfunction and, in men aged more than 65 years, occasional urinary incontinence. Greater sexual dysfunction and urinary incontinence occur in the year following radical prostatectomy. These postsurgical complication rates from patient questionnaires are greater than have been reported in other treatment series and confirm the results of two retrospective studies of patient-reported complications.

Seminal vesicle involvement by in situ and invasive transitional cell carcinoma of the bladder.

We report six cases of seminal vesicle involvement by transitional cell carcinoma of the bladder among 187 consecutive cystoprostatectomy specimens. Two of these six cases showed mucosal spread without stromal invasion (type A); the remaining four cases presented a direct extension (type B) from muscle-invasive carcinomas of the bladder. Type A involvement of the seminal vesicle was associated with a long history of superficial bladder cancer with similar mucosal spread to the prostatic ducts, acini, and ejaculatory ducts. One type A case showed extensive pagetoid spread of transitional cell carcinoma to the urethral meatus and collecting ducts of the kidney. Because the clinical significance of mucosal spread or direct invasion of seminal vesicles is not clear, pathologists and urologists need to be aware of these phenomena. More cases should be analyzed to determine further clinicopathologic implications.

Mucinous adenocarcinoma of the prostate: histochemical and immunohistochemical studies.

Twelve patients with primary mucinous adenocarcinoma of the prostate were included in a clinicopathologic study; criteria included a total tumor volume more than 25% mucinous and single or clustered tumor cells floating in mucin lakes. Patient ages were 57 to 81 years; tumor stages were C (three), D (five), and unknown (four). Bone was the most frequent metastatic site (usually osteoblastic), followed by lymph nodes and lungs. Serum levels of prostatic acid phosphatase and prostate-specific antigen were frequently elevated (five of 10 and three of three measured, respectively). All mucinous adenocarcinomas also contained other histologic patterns: microglandular (four), cribriform (three), comedo (two), solid (two), and hypernephroid (one). Mucinous components composed less than 50% of three tumors, 50% and 75% of six, and more than 75% of three. No tumor contained signet-ring cells. Immunoperoxidase staining was positive for prostatic acid phosphatase and prostate-specific antigen and negative for carcinoembryonic antigen. Treatment was radiation, estrogen, orchiectomy, or a combination. In two of four patients, serum prostatic acid phosphatase levels normalized after therapy. Seven patients died of disease (mean follow-up, 56 months), and five patients are alive with disease (mean, 32.2 months). The proportion of mucinous component did not affect prognosis.

Importance of early treatment of transitional cell carcinoma of prostatic ducts.

Twenty-three men who underwent radical cystoprostatectomy between March 1, 1983, and October 1, 1986, were found to have not only multifocal carcinoma in situ (CIS) of the bladder but also transitional cell carcinoma (TCC) of the prostatic ducts. In 18 patients TCC was limited to the epithelium lining the prostatic ducts (CIS of prostatic ducts), but in 5 patients TCC also invaded the prostatic stroma (invasive TCC of prostatic ducts). During follow-up (mean, 26 months), in 2 of the 18 patients (11%) with CIS of the prostatic ducts metastases developed. By comparison, metastatic TCC developed in 5 of 5 patients (100%) who had invasion into the prostatic stroma. Evidence indicates that patients with multifocal CIS of the bladder should be evaluated very closely for the presence of TCC of the prostatic ducts. When TCC is present in the ducts, radical cystoprostatectomy is necessary to control this lesion before it progresses to invasion. When invasion has occurred, however, radical cystoprostatectomy alone is not sufficient therapy. Since metastatic TCC develops in 100 percent of these patients, we believe that chemotherapy (either adjuvant or neoadjuvant) should be used in addition to radical cystoprostatectomy.

Squamous cell carcinoma antigen (TA-4) in penile carcinoma.

TA-4 antigen, originally isolated from women with squamous cell carcinoma of the cervix, is elevated in the sera of patients with squamous cell carcinomas of several sites, including esophagus, lungs, and head and neck. In this study, we compared the serum levels of TA-4 in normal volunteers, patients with resected penile squamous cell carcinoma, and patients with metastatic penile squamous cell carcinoma. TA-4 values were elevated in 5 of 11 patients (45%) who had metastatic disease. In 2, TA-4 was normal the first time metastasis was clinically detected but rose as the disease progressed. Moreover, in 3 patients in whom serial determinations were made, serum TA-4 values correlated well with disease progression and response to treatment. We conclude that TA-4 values are elevated in some patients with metastatic squamous cell carcinoma of the penis and may become a useful marker for monitoring response to therapy.

Results of radical nephrectomy for peripheral well-circumscribed renal cell carcinoma.

Recently, several authorities have argued that, whenever surgically feasible, parenchyma-conserving surgery rather than radical nephrectomy should be the preferred treatment for renal cell carcinoma. They affirm that the results reported following partial nephrectomy are as good as those reported following radical nephrectomy for renal cell carcinoma. However, parenchyma-conserving surgery is usually performed only for relatively small, well-circumscribed tumors that do not involve the collecting system extensively or the renal hilum. To determine the results when radical nephrectomy is used to manage similar tumors, we reviewed the clinical records and arteriograms of 111 patients with renal cell carcinoma. Review of the arteriograms showed that parenchyma-conserving surgery could have been performed in 10 cases (9%). The disease-free survival rate for these 10 patients after radical nephrectomy was 100 percent, and they had no local recurrences. On the basis of these data, we believe that radical nephrectomy remains the best treatment for all patients who have renal cell carcinoma and a normal contralateral kidney.

Benign hepatic masses mimicking metastatic renal cell carcinoma.

Making the distinction between a benign hepatic mass and renal cell carcinoma metastatic to the liver is crucial in evaluating a patient with renal cell carcinoma. The erroneous diagnosis of metastatic renal cell carcinoma may deter the surgeon from performing a potentially curative nephrectomy. In this report, we present 1 patient with cavernous hemangiomas and another patient with focal nodular hyperplasia of the liver. In each case the benign liver lesion was incorrectly diagnosed initially as metastatic renal cell carcinoma. The radiographic appearance of these lesions is discussed in detail.

Are frozen-section examinations of ureteral margins required for all patients undergoing radical cystectomy for bladder cancer?

Unsuspected malignant disease was discovered by frozen-section examination of the ureteral margins in 8 of 403 patients (2%) undergoing cystectomy for treatment of bladder cancer. Once malignant disease was demonstrated, a short segment of the proximal ureter was resected in 6 patients; in 5 instances dysplastic changes remained at the second margin, which was anastomosed to the bowel. No clinically recognized tumor developed at this site in any of the 8 patients. In an additional 26 instances (19 patients), dysplastic changes were known to be present in the ureteral margin at the time of ureteroenteric anastomoses. Again, no recognizable tumor has developed at the anastomotic site after a median follow-up of six years. We conclude that frozen-section examinations of the ureteral margins prior to constructing the ureteroenteric anastomosis are not indicated for the patient undergoing routine cystectomy for bladder cancer, but should be reserved for patients who are at increased risk for carcinoma in situ (those with multifocal bladder carcinoma in situ or transitional cell carcinoma of the prostatic ducts).

Long-term serum creatinine values after radical nephrectomy.

Both pre- and postnephrectomy levels of serum creatinine were measured in 52 consecutive patients who underwent radical nephrectomy for localized renal cell carcinoma between 1971 and 1976. At the time of follow-up, 17 patients were alive and 35 had died, 14 of renal cell carcinoma and 21 of other causes. Follow-up lasted a minimum of 115.5 months (mean 151.1 months, median 141.1, range 115.5-211.3 months) for 16 of the 17 patients who were alive. In this group only 2 patients had elevations in the serum creatinine level above 1.6 mg/dL-1.9 mg/dL and 2.4 mg/dL, respectively. The patient whose value was 2.4 mg/dL was a diabetic who required insulin. No serious renal failure, renal disease, or tumors in the contralateral kidney occurred among the total group of 52 patients. These data indicate that renal function remains adequate in patients who have a normal contralateral kidney and are treated by radical nephrectomy.

Ileal conduit in era of systemic chemotherapy.

The records of 62 patients with invasive transitional cell carcinoma of the bladder whose planned treatment was radical cystectomy with ileal conduit urinary diversion and postoperative systemic chemotherapy were reviewed. Seven of the patients received radical cystectomy but not postoperative chemotherapy as planned, 3 of them (5%) for reasons directly related to complications from the urinary diversion. Fifty-five patients received the planned postoperative chemotherapy. Complications during chemotherapy that were related to the ileal conduit were urinary tract infection in 37 percent and stenosis at the ureteroileal anastomosis requiring percutaneous nephrostomy in 3.6 percent. Chemotherapy was not discontinued in any patient, however, because of complications specifically related to the urinary diversion. We conclude that the ileal conduit is well tolerated by patients who require systemic chemotherapy and is, today, the simplest, safest, and best diversion method when systemic chemotherapy is to follow radical cystoprostatectomy.

Ketoconazole therapy for hormonally refractive metastatic prostate cancer.

Twenty-two patients who had progressive metastatic prostatic carcinoma (Stage D2) despite androgen-deprivation therapy (bilateral orchiectomy, 10 cases; bilateral orchiectomy followed by diethylstilbestrol, 7 cases; diethylstilbestrol, 3 cases; combined megestrol acetate and low-dose estrogen, 2 cases) were treated with ketoconazole. Of 19 evaluable patients, 2 (11%) achieved a partial response (for 6 and 8 months) and 7 others (37%) achieved stabilization of disease (for periods of 3-8 months). Of 16 patients in whom pain was a prominent clinical feature, 13 (81%) noted improvement in pain for periods of one to eight months (median 3 months). We conclude that ketoconazole is a useful addition to our current armory for management of patients with metastatic prostatic cancer resistant to prior hormonal therapy.

Medical castration using megestrol acetate and minidose estrogen.

Sixty-two men who presented with previously untreated metastatic carcinoma of the prostate (D0: 10 patients; D1: 29 patients; D2: 23 patients) received oral megestrol acetate (80 mg twice daily) and minidose estrogen (diethylstibestrol 0.1 mg or ethinyl estradiol 0.05 mg once daily) as a means of achieving total androgen ablation (testicular and adrenal). A high incidence of feminizing side effects (70-74%), a higher than expected rate of cardiovascular complications (18%), an unexpected need for cortisone replacement (13%), and failure of patients with Stage D2 disease to obtain results better than those of standard therapy during the first year of observation suggest this regimen offers no advantage over other more conventional therapy.

Effective outpatient use of polyethylene glycol-electrolyte bowel preparation for radical cystectomy and ileal conduit urinary diversion.

In this prospective study we examined the oral electrolyte-overload method of bowel preparation for patients who were to undergo radical cystectomy and ileal conduit urinary diversion. We found it to be a safe and effective mechanical bowel preparation that can be used by outpatients. It was well tolerated and resulted in adequate bowel cleansing and a low incidence of postoperative wound infections and pyelonephritis. A major advantage of this method is that it reduced the period of preoperative hospitalization.

Identifying patients with low-risk clinical stage I nonseminomatous testicular tumors who should be treated by surveillance.

We examined the records of 82 patients with clinical Stage I nonseminomatous germ cell tumors of the testis who, after radical orchiectomy, were treated by surveillance at M.D. Anderson Cancer Center between October, 1981, and March, 1987. Our purpose was to determine whether or not patients with a low risk of relapse can be identified at the time of the initial staging evaluation. In 30 of 82 patients (Group 1), embryonal carcinoma constituted less than 80 percent of the tumor, no vessel invasion was present, and the preorchiectomy serum AFP level was less than 80 ng/dL. No relapses occurred in this group. Fifty-two patients (Group 2) had more than 80 percent embryonal carcinoma or vessel invasion or a serum AFP level higher than 80 ng/dL. Relapse occurred in 24 (46%) of these patients. The difference in the rate of relapse between patients in Group 1 and Group 2 was statistically significant (P less than 0.00001). A separate analysis of teratoma as a predictor of nonrelapse showed that the orchiectomy specimens of 30 of the 82 patients contained more than 50 percent teratoma. Only 1 relapse occurred among 25 patients with more than 50 percent teratoma and no vessel invasion. Our data show that there is a subgroup of patients with clinical Stage I nonseminomatous germ cell tumor who have a very low rate of relapse. We believe these patients can be effectively treated by surveillance and should be spared the morbidity of an unnecessary retroperitoneal lymph node dissection.

Stage B (P2/3A/N0) transitional cell carcinoma of bladder highly curable by radical cystectomy.

Seventy-one patients with pathologic Stage B (P2/3a/N0) transitional cell carcinoma (TCC) of the bladder underwent radical cystectomy alone without preoperative radiotherapy or perioperative chemotherapy between 1983 and 1987 and have been followed a median of fifty months. The five-year actuarial survival and disease-free survival rates were 82 percent and 77 percent, respectively, and only 13 patients (18%) have relapsed. Histologic parameters were evaluated as to prognostic impact; none correlated with disease-free survival rates although the presence of vessel involvement portended a worse disease-free survival rate (68% versus 80%). During this same period, an additional 15 patients underwent radical cystectomy for pathologic Stage B disease but received adjuvant chemotherapy on the basis of vessel invasion. Their disease-free survival rate at five years was 80 percent, comparable to the disease-free survival rate for patients with vessel invasion treated by surgery alone (68%). Although the role of systemic chemotherapy in the management of invasive bladder cancer remains under investigation, it would appear that patients with Stage B TCC are best treated with radical cystectomy alone. Continued analysis of modern surgical results grouped by current pathologic staging criteria is needed to identify patients who have a relatively low risk of relapse and thus little need for additional therapeutic intervention. These results demonstrate that Stage P2/3a/N0 TCC of the bladder is highly curable by surgery.

Will Rogers and the results of radical cystectomy for invasive bladder cancer.

Disease-free survival rates for patients with muscle-invasive bladder cancer treated by radical cystectomy with bilateral pelvic lymphadenectomy with or without adjuvant chemotherapy are 75% to 80% in stage B disease, 60% in stage C disease, and approximately 50% in stage D disease. Vascular invasion is an important prognostic factor in meticulously staged patients. Powerful selection factors, including more accurate clinical and pathologic staging and improved surgery, as well as unspecified selection factors, may contribute to the improved results. In order to evaluate the impact of adjuvant chemotherapy, a randomized, controlled study is necessary.

Squamous cell carcinoma antigen in genitourinary tumors.

We have evaluated the serum levels of squamous cell carcinoma (SCC) antigen in patients with adenocarcinoma of the kidney, adenocarcinoma of the prostate, germ cell tumors of the testis, transitional cell carcinoma of the bladder, and SCC of the penis, urethra, and bladder. Serum SCC antigen levels were elevated in 5 of 11 patients (45%) with metastatic SCC of the penis, and in the 3 patients for whom serial determinations were made, the serum levels correlated correctly with the progression of disease or response to treatment. The antigen was elevated in 1 of 3 patients with SCC of the urethra, and 1 apparent false-positive value was observed in a patient with adenocarcinoma of the prostate. Otherwise, no SCC antigen elevations were noted among 10 patients with metastatic adenocarcinoma of the prostate, 8 with metastatic adenocarcinoma of the kidney, 11 with metastatic transitional cell carcinoma of the bladder, 8 with metastatic nonseminomatous germ cell tumors of the testis, and 2 patients with metastatic SCC of the bladder.

Extended resection for locally advanced colorectal carcinoma.

We reviewed the medical records of 101 patients who underwent extended resection for locally advanced colorectal carcinoma between 1965 and 1989. Preoperative symptoms related to the genitourinary system were present in 46 patients. Malignant invasion of genitourinary structures by colorectal carcinoma was found in 43 of these 46 patients (93%). In contrast, 51% of the patients without such symptoms had malignant invasion of contiguous structures. Preoperative intravenous pyelography, computerized tomographic scans, and cystoscopy correctly predicted the presence or absence of malignant invasion in 89%, 83%, and 87% of patients, respectively. Tumor-positive resection margins had a negative impact on survival (mean survival: 11.4 months). The 5-year actuarial survival rate for the patients who underwent a curative extended resection (margins tumor negative) was 54%. A thorough preoperative evaluation can identify a significant number of patients with colorectal cancer extending into adjacent organs and structures. Such evaluation is vital for operative planning and patient preparation, since an appropriate extended resection can produce long-term local control and patient survival.