Faculty Bibliography

This article presents the evolution of open radical retropubic prostatectomy (ORRP) into a minimally invasive procedure and reviews the literature to provide a legitimate comparison between ORRP and robotic-assisted laparoscopic radical retropubic prostatectomy (RALRP). The article is limited to manuscripts cited in the peer-reviewed literature, and an effort was made to identify those articles that fulfilled the highest level of medical evidence. In centers of excellence, ORRP is performed with no mortality, extraordinarily low technical and medical complications (1%), the rare need for blood transfusions, 1- to 2-day hospital stays, urinary catheters that are routinely removed in a week, the majority of men returning to work in 2 weeks, and up to 97% of men regaining urinary continence. Return of potency remains a challenge, especially for older men with marginal erections. RALRP is now the most common approach for the surgical removal of the malignant prostate. A critical review of the literature fails to support the marketing claims that RALRP is associated with shorter hospitalization, less pain, better cosmetics, shorter catheter time, lower transfusion rates, or improved continence and potency rates. The highest level of medical evidence suggests that RALRP may significantly compromise oncologic outcomes and that men undergoing this approach have higher regret rates than men undergoing ORRP

This study provides further insights into those preoperative parameters that predict side-specific risk of pathological stage in men undergoing radical prostatectomy (RP). The transrectal ultrasound-guided tissue biopsy cores obtained from the right and left sides of the prostate were collected in separate jars and examined independently according to the side of origin in 1250 men with clinically localized prostate cancer who underwent RP. The side-specific biopsy specimens were examined for Gleason score, number of positive cores, percentage of positive cores, percent tumor volume in the biopsy specimens and the presence of perineural invasion. All of the surgical specimens were processed and analyzed by pathologists at NYUMC using a standardized protocol. The surgical specimens were examined for side-specific extracapsular extension (ECE) and seminal vesicle invasion (SVI). Using a univariate analysis, age, serum prostate-specific antigen (PSA), prostate volume, clinical stage, Gleason score, number of positive biopsies, percent positive biopsy cores, percent volume of prostate cancer in cores and perineural invasion were all significant predictors of both ECE and SVI. A multivariate analysis was performed to determine the independent predictors of ECE and SVI. Serum PSA, biopsy Gleason score, percent volume of biopsy cores with cancer and perineural invasion were independent predictors of side-specific ECE. Age, serum PSA, Gleason score and prostate volume were independent predictors of side-specific SVI. Our study identified previously unrecognized independent predictors of side-specific ECE and SVI. Our study also provides evidence that the independent predictors of ECE and SVI are different

PURPOSE: We describe our new technique of transabdominal sonocystography in men following radical prostatectomy. MATERIALS AND METHODS: From May 2007 to January 2008, 75 men underwent gravity transabdominal sonocystography and fluorocystography 8 days following open radical retropubic prostatectomy. Bladder volume after the instillation of 150 cc saline was determined by measuring bladder height, width and length in the longitudinal and transverse planes. Extravasation volume was calculated by subtracting the calculated bladder volume after filling from a volume of 165 ml, which represents the instilled saline volume of 150 ml plus 15 ml in the urinary catheter balloon. Extravasation was then qualitatively graded as none, slight, moderate or severe after instilling 150 cc contrast medium into the bladder. RESULTS: The correlation between fluorocystography and transabdominal sonocystography was ascertained by determining the mean extravasation volume corresponding to the qualitatively graded categories of extravasation determined fluoroscopically. Mean extravasation volume in cases with no, slight and moderate extravasation on fluoroscopic cystography was -3.72, 6.51 and 46.0 ml, respectively. At an extravasation volume of 20 ml the sensitivity and specificity of transabdominal sonography to differentiate no or slight vs moderate or severe fluoroscopic extravasation was 100%. CONCLUSIONS: The advantages of transabdominal sonocystography over fluorocystography are lower cost, lack of radiation exposure and the ability to perform the procedure at most urological outpatient facilities. Therefore, transabdominal sonocystography represents a good alternative to fluorocystography for assessing the integrity of the vesicourethral anastomosis following open radical retropubic prostatectomy

OBJECTIVE: To characterize the effect of preserving the neurovascular bundle (NVB) and of potency on urinary continence after open radical retropubic prostatectomy (ORRP). PATIENTS AND METHODS: Between October 2000 to September 2005, 1110 consecutive continent men had ORRP by one surgeon. The University of California Los Angeles Prostate Cancer Index was self-administered at baseline and 3, 6, 12, and 24 months after ORRP. Men were considered continent if they responded that they had total urinary control or had occasional urinary leakage. Men were considered potent if they engaged in sexual intercourse with or without the use of phosphodiesterase inhibitors at least once in the month before or after ORRP. Of the 1110 men, 728 (66%) were potent and continent at baseline. Men undergoing adjuvant hormonal therapy, radiation therapy or chemotherapy were excluded. The potency status was evaluated in 610 men at 24 months after ORRP, and the number of NVBs preserved was recorded at the time of ORRP. RESULTS: Of men who were potent at baseline and had bilateral vs unilateral nerve sparing, 96% and 99% were continent at 24 months, respectively (P = 0.50). Of the men who were potent and impotent at 24 months, 98% and 96% were continent at 24 months, respectively (P = 0.25). Continence did not depend on whether men regained potency or whether they had a bilateral or a unilateral nerve-sparing procedure. CONCLUSION: Our observation that only 60% of men undergoing bilateral nerve-sparing ORRP regain potency suggests that the NVBs are often inadvertently injured, despite efforts to preserve them. We feel that potency status is the best indicator of the true extent of NVB preservation. That men undergoing bilateral vs unilateral nerve-sparing procedures, and that potent vs impotent men at 24 months have similar continence rates, provides compelling evidence that nerve-sparing is not associated with better continence. Based on these findings, NVBs should not be preserved in men with baseline erectile dysfunction, with the expectation of improving continence

OBJECTIVES: Development of acute urinary retention (AUR) is common in the aging male. The pathophysiology of AUR is attributed primarily to prostatic obstruction. The objective of this study was to evaluate the risk of AUR in men after open radical prostatectomy (ORRP). METHODS: A questionnaire asking whether a urinary catheter had been inserted after its initial removal was sent to 1361 men who underwent ORRP by a single surgeon (HL) between October 2000 and January 2007. Follow-up ranged from 12 to 84 months (mean, 48 months). For those who responded that a catheter had been reinserted, a follow-up question inquired specifically when this event occurred. The reason for postprostatectomy catheter reinsertion was determined via phone interview. RESULTS: A total of 952 men (69.9% response rate) mailed a completed questionnaire to our database manager. No men underwent catheter reinsertion owing to spontaneous AUR. Ninety-two men (9.7%) answered 'yes' to requiring catheter insertion postprostatectomy. The reasons for recatheterization were an intermittent catheterization regimen after dilation of an anastomotic stricture or meatal stenosis (n = 68), AUR immediately after initial catheter removal (n = 14), and elective reasons (n = 10). All urethral strictures were dilated within the first year after surgery and no patient with stricture presented with AUR. CONCLUSIONS: The risk of spontaneous AUR after 1 month of catheter removal after ORRP is 0%. We believe that this is an important unrecognized clinical benefit of ORRP, especially in men with moderate to severe lower urinart tract symptoms or enlarged prostates, who are at higher risk for AUR

PURPOSE: To determine the maximum-tolerated dose (MTD) of concurrent paclitaxel and radiation therapy (RT) in patients with locally advanced prostate cancer. MATERIALS AND METHODS: Eligible patients had T2-4 tumors with Gleason scores greater than 7 and/or PSA levels greater than 10 ng/mL and/or had tumors with pathologic stage TxN1. Hormonal ablation was initiated 3 months before RT and was given for 9 months. RT was delivered daily (1.8 Gy) with concurrent twice-weekly paclitaxel (30 mg/m(2)). The whole pelvis was irradiated to 39.6 Gy. The radiation dose was escalated as follows: 63 Gy, 66.6 Gy, 70.2 Gy, and 73.8 Gy. The last RT dose level was fixed at 73.8 Gy. RESULTs: Between January 2000 and October 2006, 22 patients were enrolled. The median age was 59 years (range, 48 to 72 years); the median PSA level was 22.4 ng/mL (range, 2.8 to 113 ng/mL). The number of patients per stage was as follows: three with T1, eight with T2, 11 with T3, and five with pN1 = 5. No grade 3 toxicities occurred at 63 Gy. Grade 3 diarrhea occurred in three patients at 66.6 Gy. The protocol then was amended to treat the prostate volume first followed by the whole pelvis. No grade 3 toxicities were observed at 70.2 Gy. One patient experienced grade 3 diarrhea at 73.8 Gy. Five additional patients were treated to 73.8 Gy without grade 3 toxicity, which established the MTD for combined paclitaxel and RT at 73.8 Gy. At 38 months median follow-up (range, 9 to 87 months), 21 (95%) of 22 patients are alive. Six (27%) of 22 experienced recurrence. CONCLUSION: Concurrent biweekly paclitaxel with RT is feasible, with an MTD of 73.8 Gy. Recovery of gonadal function occurs in the majority of patients. These results encourage testing in a phase III setting