Faculty Bibliography

OBJECTIVE: To evaluate the efficacy of local compression and topical epinephrine in controlling perioperative bleeding during open radical retropubic prostatectomy (ORRP) and its impact on the degree of urinary extravasation on initial postoperative cystogram. METHODS: Between September 2005 to March 2009, 476 men underwent ORRP performed by a single surgeon. Group 1 (n = 200) underwent ORRP between September 2005 and November 2006 without pelvic compression; Group 2 (n = 76) underwent ORRP between November 2006 and May 2007 and a dry laparotomy pad was positioned in the pelvis immediately prior to abdominal wound closure; Group 3 (n = 200) underwent ORRP between May 2007 and March 2009 with a epinephrine soaked laparotomy pad positioned in the pelvis prior to abdominal wound closure. Hematocrit values were obtained prior to anesthesia induction, upon arrival in the recovery room and at hospital discharge in order to estimate intraoperative and postoperative bleeding. The number of allogenic and autologous units transfused was recorded. The utility of compressing the pelvis with a pad was examined by comparing estimated postoperative bleeding between Group 1 versus Groups 2 and 3 and the hemostatic utility of soaking the pad in epinephrine was examined by comparing Group 2 versus 3. Systolic and diastolic blood pressure and pulse measurements were obtained at baseline and 5 and 10 minutes after introducing the epinephrine pad. The relationship between estimated blood loss and degree of extravasation on initial postoperative cystogram was investigated. RESULTS: Estimated intraoperative, postoperative and total blood loss (mean change in Hct) was 12.2, 2.3, 14.2, in Group 1, 10.0, 1.5, 11.1 in Group 2, and 10.8, 2.1, and 12.6 in Group 3. Estimated intraoperative and total blood loss was significantly less in the men treated with a compression pad (Groups 2 and 3) versus no pad (Group 1). There were no significant differences in number of patients transfused, the number of units transfused or the degree of extravasation on postoperative cystograms between Group 1 versus Group 2 and 3 or Group 2 versus 3. However, postoperative bleeding was significantly less in Group 2 compared to Group 3. Mean systolic and diastolic blood pressure and pulse values were unchanged from baseline after epinephrine use. CONCLUSIONS: Local compression of the pelvis with or without epinephrine prior to abdominal wound closure does not appear to have beneficial effects on reducing postoperative bleeding and decreasing the degree of urinary extravasation on cystogram following ORRP. While the use of topical epinephrine appears to be safe and relatively inexpensive, at the concentrations used in our study it does not appear to facilitate postoperative hemostasis

BACKGROUND: Transurethral resection of the prostate (TURP) has been the gold standard of the treatment of benign prostatic hyperplasia (BPH). In recent years there has been a significant shift in the treatment of BPH and guidelines emphasize minimally invasive surgery as a new treatment option. Minimal invasive technologies (MITs), such as transurethral microwave thermotherapy (TUMT), laser ablations, transurethral needle ablation (TUNA) have emerged as an alternative to the TURP. OBJECTIVES: To assess the retreatment rates of the most commonly used minimal invasive techniques. SEARCH STRATEGY: Durability articles were selected by using defined search terms using PubMed as search engine. RESULTS: Comparing to the overall retreatment rates of MITs the results show that TUMT, holmium laser enucleation of the prostate (HoLEP) and contact laser vaporization (CLV) are among the treatments with the lowest retreatment rates. Studies show no significant differences in retreatment rates between TUMT and TURP. CONCLUSION: A review of the current literature, long term results and retreatment rates of MITs shows large variability in outcomes and retreatment rates. The true definition of a MIT remains unclear. High energy TUMT deserves reconsideration in clinical practices, due to low retreatment rates and the low need of anesthetics

PURPOSE: To our knowledge we report the first large, randomized, prospective penile rehabilitation clinical trial to compare the effectiveness of nightly intraurethral alprostadil vs sildenafil citrate after nerve sparing prostatectomy. MATERIALS AND METHODS: We performed a prospective, randomized, open label, multicenter American study in men with normal erectile function who underwent bilateral nerve sparing radical prostatectomy. The International Index of Erectile Function erectile function domain was the primary end point. Subjects initiated nightly treatment within 1 month of surgery with intraurethral alprostadil or oral sildenafil citrate (50 mg) for 9 months. After 1-month washout and before sexual activity subjects self-administered sildenafil citrate (100 mg) for a total of 6 attempts in 1 month. Secondary end points were the global assessment question, sexual encounter profile, Erectile Dysfunction Inventory of Treatment Satisfaction and measured stretched penile length. RESULTS: Of 139 men who started intraurethral alprostadil and 73 who started sildenafil citrate, 97 and 59, respectively, completed the trial. There were no statistically significant differences in International Index of Erectile Function erectile function domain and intercourse success rates to intraurethral alprostadil. The global assessment question was significantly better only at 6 months for intraurethral alprostadil (p <0.028). At completion there were no differences between treatments for any of the end points. CONCLUSIONS: This is the first study to directly compare the ability of alprostadil and a phosphodiesterase-5 inhibitor to enhance penile recovery subsequent to bilateral nerve sparing radical prostatectomy. The use of nightly subtherapeutic intraurethral alprostadil is well tolerated after radical prostatectomy. The benefit to return of erectile function of nightly sildenafil citrate and subtherapeutic intraurethral alprostadil appears to be comparable within the first year of surgery

OBJECTIVES: To critically examine the cardiovascular and thromboembolic risks associated with erythropoietin stimulating proteins (ESPs) in men with normal hemoglobin levels undergoing open radical retropubic prostatectomy. METHODS: Between October 1, 2000, through December 31, 2006, a total of 1308 men underwent open radial retropubic prostatectomy by a single surgeon. Of these men, 1095 received preoperative ESPs. Hematocrit levels measured at baseline, immediately before anesthesia induction and at hospital discharge, were prospectively entered into a database. Thromboembolic and cardiovascular complications were prospectively captured during the hospitalization and after surgery. RESULTS: The mean Delta preoperative hematocrit level was 5.9 g/dL. The pre-anesthesia induction hematocrit level was 49.2%. Hospital discharge hematocrit level was 33.6 g/dL. The overall risk of cardiovascular and thromboembolic complications in men receiving ESP were 0.55% and 0.45%, respectively. The risk of cardiovascular and thromboembolic complications were independent of the Delta in preoperative hematocrit or the absolute level of the pre-anesthesia induction hematocrit. CONCLUSIONS: ESPs represent a safe and effective preoperative blood management strategy for men undergoing open radical retropubic prostatectomy

In order to determine the effects of therapeutic and supratherapeutic doses of silodosin on QT interval, healthy men (N = 186; aged 18-45 years) were randomized to receive silodosin (8 or 24 mg) or placebo for 5 days or moxifloxacin 400 mg (positive control, known to prolong QT) once on day 5. At baseline and on day 5, five ECGs were recorded 0.25 h before dosing and 1, 1.5, 2, 3, 4, 6, 8, 10, and 23.5 h after dosing. Adjusted mean differences (analysis of covariance) between silodosin and placebo in the change in individual heart rate-corrected QTc (QTcI) from baseline to day 5 were <5 ms at all times (all 90% confidence interval (CI) upper limits <10 ms). The QTcI difference for moxifloxacin compared with placebo often exceeded 5 ms, establishing assay sensitivity. For silodosin, no statistically or clinically significant correlation was seen between plasma concentration and QTcI, and no clinically important effects on heart rate, PR segment, QRS complex, or morphologic ECG data were observed

Context: Although open radical retropubic prostatectomy (ORRP) remains the gold standard, the past years have seen a rise in both laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP), and many patients seem to prefer the so-called minimally invasive procedures despite insufficient data demonstrating superiority over the established standard (ORRP). Objective: This article seeks to review the most recent data on a variety of aspects of the different techniques for performing prostatectomies, such as cost, oncologic outcomes, continence, quality of life, and marketing and propaganda as well as the learning curve for each. Evidence acquisition: A search of the most recent literature was performed using PubMed, and data from lectures and presentations given at international conferences were used. Evidence synthesis: The review showed that, overall, LRP and RARP outcomes have not proved superior to ORRP outcomes or resulted in anticipated benefits to patients. In addition, current data seem to suggest that results of any of the procedures depend more on the surgeon's ability than on the approach, with rates of blood loss, positive surgical margins, incontinence, and erectile dysfunction varying widely from surgeon to surgeon with all three techniques. The aggressive marketing associated with RARP has also led to significantly higher rates of dissatisfaction and regret in patients. Conclusions: Considering the evidence, ORRP remains the gold standard in radical prostatectomies. Moreover, although the differences among major outcomes are minor and associated with shorter lengths of stay, the costs associated with LRP and RARP are significantly higher than with ORRP. In the absence of solid scientific evidence, patient education, and counselling are crucial parts of the decision-making process, during which patients will opt for one treatment over another. (C) 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved

Prior to the description of the anatomic nerve sparing radical prostatectomy, most men were rendered impotent following radical perineal or retropubic prostatectomies. The fact that these 'erection' nerves were localized outside the prostate suggested the feasibility of totally eradicating localized prostate cancer with preservation of erectile function in selected cases. All of these studies collectively suggest that unilateral excision of neurovascular bundles will compromise potency rates in between 15% to 20% of cases. It seems logical to report the risk of extracapsular extension independently for the two sides of the prostate, especially since independent decisions are made relative to the nerve sparing status of the different sides. Extracapsular extension is a risk factor for positive surgical margins. Positive surgical margins represent an independent risk factor for biochemical recurrence following radical prostatectomy. The surgeon is left with the dilemma of whether to maximize potency at the risk of compromising cancer control. In cases with a 30% risk of side specific extracapsular extension, using the above assumption, the risk of developing a positive surgical margin and biochemical recurrence is only 4.7% and 2%, respectively