Seminars in urologic oncology最新文献

Radical prostatectomy can be an effective therapy for men with organ-confined disease. However, extension beyond the confines of the prostate (pT3) can be found in many men, and this is often associated with longterm prostate-specific antigen (PSA) failure. Not all patients will progress with pT3 disease. The identification of additional adverse prognostic features (high Gleason score, PSA greater than 10 ng/mL, and seminal vesical invasion) can help identify those men at highest risk of progression following definitive surgery. The role of postoperative therapy in patients with high-risk features is often controversial. The lack of long-term survival benefit, toxicity, and cost are often cited. We reviewed our experience with a unified approach to this patient population and performed matched-pair analysis of patients with similar adverse prognostic features treated with and without postoperative radiation therapy. For our series, the results indicate that the addition of adjuvant radiation therapy is associated with a significantly reduced risk of PSA recurrence. The 5-year bNED rate after adjuvant radiation therapy was 89% (95% CI: 76% to 100%) compared with 55% (95% CI: 34% to 79%) after surgery alone (P = .002). This benefit also appears to hold true for men with pathological involvement of their seminal vesicles. A dose-response curve was observed with improved disease control above a level of 61.2 Gy. Appropriate patient selection and delivery of an adequate dose of radiation can improve the PSA recurrence of most patients with pT3 disease.

The technique of continence-preserving anatomic radical retropubic prostatectomy focuses on the preservation of the following anatomic components of the external striated urethral sphincteric complex: (1) the entire circumference of the rhabdosphincter musculature, (2) the periurethral fascial investments (the pubourethral ligaments anterolaterally and median fibrous raphe posteriorly), and (3) the innervation of both the rhabdosphincter by way of the intrapelvic branch of the pudendal nerve (somatic) and the mucosal and smooth muscle components by way of the urethral branch of the inferior hypogastric plexus (autonomic). The clinical impact of preserving the external striated urethral sphincter and its innervation by performing a continence preserving anatomic retropubic prostatectomy is a shorter time to achieve urinary continence.

Initial incision of the lateral pelvic fascia before division of the dorsal vein complex allows posterior displacement of the neurovascular bundles and development of the proper prostatorectal plane. This technique may decrease positive surgical margins while preserving the neurovascular bundles. This technique also completely preserves the posterior attachments to the urethra, allowing preservation of maximal urethral length.

Nerve-sparing radical retropubic prostatectomy is a reasonable treatment option in localized prostate cancer with minimal morbidity. Recent techniques in neurovascular bundle preservation could lead to an overall improvement in postoperative quality of life without compromising cancer control in the appropriately selected patient. Different techniques for neurovascular bundle preservation have been described by most major centers. This brief article describes the updated technique of nerve-sparing radical retropubic prostatectomy for clinically localized prostate cancer. Our technique of nerve dissection starts at the lateral aspect of the prostate with secondary urethral dissection. We believe this technique is easy to learn and decreases dissection around the striated sphincter.

Considerable variation exists in the reported results of nerve-sparing prostatectomy with respect to potency preservation. This may reflect differences in surgical technique. The Cavermap is a device that uses intraoperative nerve stimulation with real time tumescence monitoring to permit identification of the course of the cavernous nerve fibers during radical prostatectomy. Results of a single center phase 2 and a blinded multicenter phase 3 study have demonstrated an improved outcome compared with conventional nerve sparing with respect to Rigiscan-measured nocturnal erection at 1 year after prostatectomy. The device permits evaluation of the success of nerve-sparing during surgery. Further studies of the effectiveness of the Cavermap device are warranted.

Despite improvements in knowledge and technique, a growing number of patients experience incontinence after radical prostatectomy. This may be the result of damage to sphincteric structures, bladder dysfunction, an obstructive stricture, or some combination of these. After an appropriate interval to allow for improvement, the patient should undergo a thorough evaluation to assess the contribution of the various causes and should then be managed using a sequential treatment approach. Following restoration of adequate emptying, bladder dysfunction should be controlled first, if present, and persistent stress incontinence should then be managed according to its severity. Many patients with significant persistent incontinence after radical prostatectomy will need to consider placement of an artificial urinary sphincter.

The purpose of this article is to reduce the incisional morbidity associated with standard radical retropubic prostatectomy using the minilaparotomy incision developed for pelvic lymph-node dissection, which was applied to radical retropubic prostatectomy. More than 522 patients underwent minilaparotomy radical retropubic prostatectomy from 1991 to 1997. Preoperative evaluation included history, physical examination, prostate-specific antigen (PSA), and Gleason's grade. Postoperative follow-up included serial PSA measurements and a determination of continence. The surgical technique is described in detail. Two hundred sixty-five patients responded to the mailed questionnaire out of a total 522 patients. Satisfactory continence, defined as 0 to 1 pad per day, was achieved in 85% of patients, and 83% of patients had a PSA < 0.2 at an average follow-up of 2.6 years. There was no operative mortality, and overall complication rate was similar to other surgeons. The typical patient was discharged home 3 days postoperatively. Minilaparotomy radical retropubic prostatectomy compares favorably with standard radical retropubic prostatectomy.

Indwelling urethral catheters are bothersome for patients following radical retropubic prostatectomy. At Indiana University, to alleviate postoperative discomfort, early removal of urethral catheters has become commonplace. In our series of patients, complications were infrequent and removal improved patient mobility and reduced discomfort.

Prostate cancer is the most common solid malignancy and the second most common cause of cancer death in man. Radical prostatectomy is the therapeutic modality that currently provides the best long-term biochemical relapse-free survival rate. Yet many patients select alternative forms of therapy or no therapy at all because of fears that treatment will significantly alter quality of life. Urinary incontinence following radical prostatectomy has a significant deleterious effect on quality of life and, unfortunately, is much more prevalent following surgery compared with other treatment modalities, such as radiation therapy. Many efforts have been undertaken to avoid this complication with only modest success achieved. These include creation of a neobladder neck, bladder neck preservation, periurethral injection of bulking agents, and anterior urethropexy. A technique for radical retropubic prostatectomy that spares the puboprostatic ligaments, which preserves the normal anterior support of the urethra, is described herein. The outcome following this procedure demonstrates more rapid return of full urinary continence following radical prostatectomy in a controlled study. However, the "Holy Grail" of complete eradication of urinary incontinence following radical prostatectomy has not been achieved.