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Purpose: This study was initiated to determine the efficacy of post-prostatectomy therapeutic radiation for patients with elevated prostate specific antigen (PSA).Materials and Methods: A total of 47 patients received 66 Gy. therapeutic irradiation to the prostate bed for a PSA level greater than 0 ng./ml. postoperatively. Univariate and multivariate survival analyses were performed to identify prognostic variables.Results: At a median followup of 36 months (range 18 to 48) 83 and 33% of the patients with PSA 2 ng./ml. or less and 2 ng./ml. or greater, respectively, had no evidence of disease (p = 0.001). Pathological stage and a complete biochemical response (PSA less than 0.05 ng./ml.) were also significant prognostic variables.Conclusions: Therapeutic irradiation for patients with elevated PSA postoperatively is highly effective. At a median followup of 36 months 64% of the patients remain disease-free.

Ian Thompson (Chair),* James Brantley Thrasher (Co-Chair),† Gunnar Aus,‡ Arthur L. Burnett,§ Edith D. Canby-Hagino, Michael S. Cookson,¶ Anthony V. D’Amico, Roger R. Dmochowski, David T. Eton, Jeffrey D. Forman, S. Larry Goldenberg, Javier Hernandez, Celestia S. Higano, Stephen R. Kraus,** Judd W. Moul†† and Catherine M. Tangen (Prostate Cancer Clinical Guideline Update Panel) From the American Urological Association Education and Research, Inc.

In conjunction with the assignment to update the Guidelines for Management of Clinically Localized Prostate Cancer, the American Urological Association Prostate Cancer Guideline Update Panel performed a side analysis of the reporting of erectile function outcomes in this clinical context as published in the medical literature.Four National Library of Medicine PubMed(R) Services literature searches targeting articles published from 1991 through early 2004 were done to derive outcome reporting (efficacy or side effects) for the treatment of clinical stage T1 or T2 N0M0 prostate cancer. A database was constructed containing descriptions relating to erectile function as well as numerical frequency rates of complete erectile dysfunction, and partial and intact erectile function for various treatments. A literature review was also done, consisting of a PubMed Services search of current measures and protocols used for assessing erectile function outcomes and a survey of consensus opinion sources on the management of male sexual dysfunctions.Based on inclusion criteria 436 articles were selected. Of these articles database extraction from 100 pertaining to radical prostatectomy garnered various characterizations of erectile function, including qualitative descriptions, generic terminology and rating systems. Database extraction from 31 articles, in which results for at least 50 patients were reported, yielded ranges of rates for complete erectile dysfunction, partial erectile function and intact erectile function that were 26% to 100%, 16% to 48% and 9% to 86% for radical prostatectomy, 8% to 85%, 21% to 47% and 36% to 63% for external beam radiation, and 14% to 61%, 21% and 18% for interstitial radiation, respectively. The literature review showed an evolution in standards for studying and reporting erectile function outcomes.Clinical studies reporting erectile function outcomes after localized prostate cancer treatment often demonstrate poorly interpretable and inconsistent manners of assessment as well as widely disparate rates of erectile dysfunction and erectile function. Future studies must apply scientifically rigorous methodology and standard outcomes measures to advance this field of study.

The American Urological Association Prostate Guideline Update Panel was charged with updating the Guidelines for Clinically Localized Prostate Cancer. In assessing outcomes with treatment, it became apparent that a highly variable number of definitions exist with respect to biochemical recurrence. Herein, we review the variability in published definitions of biochemical recurrence and make recommendations directed toward improving this terminology by recommending a standard definition in patients treated with radical prostatectomy.Four PubMed literature searches were performed between May 2001 and April, 2004 and covered articles published from 1991 through early 2004. The search terms included the MeSH major headings of prostate cancer and prostatic neoplasm. All potentially relevant articles were retrieved and a more detailed screen for relevance was performed. An article was considered relevant if it reported treatment outcomes of patients with clinical T1 or T2N0M0 prostate cancer. Data extractors recorded the definition of biochemical recurrence and definitions were then collapsed into categories representing the same criteria. The results of biochemical failure were subcategorized by initial treatment.Of 13,800 citations, a total of 436 articles were selected. Among these, a total of 145 articles contained 53 different definitions of biochemical recurrence for those treated with radical prostatectomy. Of these, the most common definition (35) was a prostate specific antigen of0.2 ng/mL or a slight variation thereof. In addition, a total of 208 articles reported 99 different definitions of biochemical failure among those treated with radiation therapy. Of these, the American Society for Therapeutic Radiology and Oncology definition (70) and/or a variation thereof was the most commonly reported. In total, 166 different definitions of biochemical failure were identified. Following radical prostatectomy, the Panel recommends defining biochemical recurrence as an initial serum prostate specific antigen ofor =0.2 ng/mL, with a second confirmatory level of prostate specific antigen of0.2 ng/mL. The Panel recommends the use of the American Society for Therapeutic Radiology and Oncology criteria for patients treated with radiation therapy and acknowledges that these criteria will soon be updated although not yet published.A high degree of variability in the definition of biochemical recurrence exists following treatment for localized prostate cancer. Strict definitions for biochemical recurrence are necessary to identify men at risk for disease progression and to allow meaningful comparisons among patients treated similarly. The Panel acknowledges the American Society for Therapeutic Radiology and Oncology criteria and future modifications thereof for those receiving radiation therapy and recommends the newly developed American Urological Association criteria for those treated with radical prostatectomy. The purpose for the establishment of this standard is for data reporting purposes and for comparison of similarly treated patients. It is not intended to represent a threshold value for which to initiate treatment. The Panel acknowledges that the clinical decision to initiate treatment will be dependent on multiple factors including patient and physician interaction rather than a specific prostate specific antigen threshold value.

We evaluated the success and possible complication rates of penile implant surgery in patients who underwent external beam radiation therapy for prostate cancer.We reviewed the charts of 43 patients who underwent penile implant surgery after radiation therapy for prostate cancer. The type, dose and volume of radiation were assessed. The types of surgical approach and prosthesis as well as complications were recorded. A total of 34 patients was alive and traceable, and 9 were untraceable (7 dead and 2 missing). The 34 traceable patients were interviewed personally or by telephone to evaluate the function of and satisfaction with the penile implant. Followup of the 9 untraceable patients was assessed through a chart review.A total of 35 patients (81%) received definitive radiation therapy to the prostate and seminal vesicles, and 8 (19%) underwent radical retropubic prostatectomy followed by radiation therapy to the prostatic bed. Mean age at implant surgery was 67 years (range 36 to 83). In the 43 men 46 procedures were done and mean followup was 40 months. None of the patients in this series had infection or erosion. Of the men 24 (71%) use the prosthesis at least once weekly or more for sexual intercourse, 6 (17%) use it twice monthly, 4 (12%) are not sexually active despite a functioning implant, 2 are not sexually active because of a lack of sexual partners, and 2 are not satisfied with the implant and would not recommend this device. Discomfort from the penile implant was reported by 2 patients, although they currently use the implant for intercourse at least twice weekly.Penile prosthesis surgery can be safely and effectively performed after radiation therapy with minimal intraoperative and postoperative complications, and an excellent patient satisfaction rate.