Faculty Bibliography

OBJECTIVES: To determine whether repeat biopsy is necessary when the diagnosis of high-grade prostatic intraepithelial neoplasia (HGPIN) is made with a 12-core biopsy. Repeated biopsy has been recommended for individuals with HGPIN noted on sextant prostate biopsy because of the high likelihood of cancer detection. Recently, we have recommended the routine use of 12 cores, rather than 6, to improve cancer detection. METHODS: The charts of all patients undergoing prostate biopsy during a 2-year period at the Manhattan Veterans Administration Medical Center were reviewed. Patients diagnosed with HGPIN on a 12-core biopsy were identified, and those undergoing a repeat 12-core biopsy within 1 year of the initial biopsy were evaluated to determine the rate of cancer detection. RESULTS: A total of 619 men underwent biopsy during the study period. Of 103 men diagnosed with HGPIN, 43 underwent a repeat biopsy within 1 year at the discretion of the managing urologist. The mean age and median prostate-specific antigen level of those undergoing a repeat biopsy was 65.5 years and 5.37 ng/mL, respectively. At the time of the repeat biopsy, 1 patient was found to have cancer (2.3%), 20 had HGPIN (46.5%), 20 had benign pathologic findings (46.5%), and 1 patient (2.3%) had atypical small acinar proliferation. CONCLUSIONS: A repeat biopsy after the diagnosis of HGPIN on 12-core prostate biopsy rarely results in cancer detection. In the absence of other factors increasing the suspicion of cancer, immediate repeat biopsy for HGPIN diagnosed on a 12-core biopsy is unnecessary

PURPOSE: We critically examined the intraoperative and postoperative complications associated with radical retropubic prostatectomy in the modern era. MATERIALS AND METHODS: Between April 18, 1994 and July 13, 2000, 1,000 men underwent radical retropubic prostatectomy performed by a single surgeon. The whole inpatient hospital medical record of 909 patients, the outpatient charts of 955 and a self-administered patient survey completed by 679 were reviewed by 2 data managers not involved in surgical management or followup care. In all 1,000 cases at least 1 of the 3 data sources was reviewed. RESULTS: Mean patient age was 60.3 years. In 73%, 99.8% and 95.7% of cases serum prostate specific antigen was 10 ng./ml. or less, disease was clinical stage T1 or T2 and Gleason score was 7 or less, respectively, while 19.9% of pathological specimens showed positive margins. There were 8 intraoperative complications (0.8%). All 5 rectal injuries and the single ureteral injury were detected during the initial surgical procedure and repaired without sequelae. Only 14 men (1.4%) had any other complications during hospitalization. Until postoperative day 30, 4 pulmonary emboli (0.4%) with or without deep vein thrombosis and 5 myocardial infarctions (0.5%) developed. There were no intraoperative or in-hospital postoperative deaths and only 1 postoperative death secondary to myocardial infarction during the initial 30 days. Reexploration was done for hemorrhage and a disrupted anastomosis in 3 and 2 cases, respectively. Mean hospitalization was 2.3 days, 9.7% of patients required allogenic blood transfusion and 15 (1.5%) were rehospitalized. CONCLUSIONS: Our series represents a rigorous assessment of the complications associated with radical retropubic prostatectomy. It shows that in the hands of an experienced urological surgeon, this procedure is associated with minimal intraoperative and postoperative morbidity. Of the patients 98% had no intraoperative or postoperative complications. Our series enables appropriate contemporary comparisons to be made with laparoscopic prostatectomy and radiation therapy. This outcomes analysis implies that radical retropubic prostatectomy cannot be assumed to have greater morbidity than radiation therapy and it sets a high standard for those advocating laparoscopic radical prostatectomy

OBJECTIVES: To determine the feasibility and desirability of removing the urinary catheter 7 days after radical retropubic prostatectomy. METHODS: Between February 28, 2000 and October 5, 2000, 184 men underwent radical retropubic prostatectomy by a single surgeon. Of these men, 97% underwent gravity cystography under fluoroscopic control on postoperative day (POD) 7. The indwelling urinary catheter was removed on POD 7 if no evidence of extravasation was observed on cystography. Patients completed a self-administered questionnaire at the time of catheter removal to capture the degree of bother from incisional pain and the indwelling urinary catheter during the recovery period. The level of urinary continence was determined at 3 months after radical retropubic prostatectomy. RESULTS: One hundred thirty-five of the cystograms (75%) had no evidence of extravasation. The indwelling catheters were removed in 130 (97%) of 135 cases. The body weight, surgical specimen weight, presence or absence of intraoperative anastomotic extravasation, volume of pelvic drainage recorded from the Hemovac drain, and creatinine level of the pelvic drainage fluids did not predict the finding of extravasation on the POD 7 cystogram. Fifteen percent of the men whose catheters were removed on POD 7 developed acute urinary retention. At 3 months, 72% of men required no or a single protective pad, and 87% indicated they experienced no or slight bother from incontinence. These continence outcomes are comparable with a historical control group by the same surgeon who underwent catheter removal on POD 14. Forty-five percent of the men reported the catheter caused moderate to severe bother, compared with only 19% of men who indicated moderate to severe bother from incisional pain. In retrospect, 95.6% of men indicated willingness to undergo cystography on POD 7 with the intent of early catheter removal. CONCLUSIONS: The results of our study suggest that most men will have no extravasation on a cystogram performed on POD 7 and that removing the catheter at this time in these cases does not increase the risk of complications or compromise overall urinary continence. The urinary catheter is a significant bother and limits physical activity during the postoperative period. Cystography and early removal of the catheter is both feasible and desirable and should be offered to men after radical retropubic prostatectomy