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Objectives To evaluate the long-term outcomes of patients with high Gleason sum 8-10 at radical prostatectomy (RP) and to identify the predictors of prostate cancer-specific survival (CSS) in this cohort. Methods The institutional RP database was queried. A total of 9381 patients with complete follow-up underwent RP from 1982 to 2008. Of these 9381 patients, 1061 had pathologic Gleason sum 8-10 cancer. The patient and prostate cancer characteristics were evaluated. Survival analyses were performed using the Kaplan-Meier method. Univariate and multivariate proportional hazard regression models were created to evaluate the pertinent predictors of CSS (death from, or attributed to, prostate cancer). Results The median preoperative prostate-specific antigen level was 7.6 ng/mL; 435 men had clinical Stage T1 tumor, 568 had Stage T2, and 36 had Stage T3. The biopsy Gleason sum was 7 in 244 (22.3%), 406 (37.2%), and 425 (38.9%) patients, respectively. The median follow-up was 5 years (range 1-23). The actuarial 15-year recurrence-free survival, CSS, and overall survival rate was 20.7%, 57.4%, and 45.4%, respectively. On multivariate analysis, the predictors of poor CSS were pathologic Gleason sum 9-10 and seminal vesicle and lymph node involvement. Patients with pathologic Gleason sum 8 and organ-confined disease had a CSS rate of 89.9% at 15 years. Conclusions The results of our study have shown that 80% of the men with Gleason sum 8-10 who undergo RP will have experienced biochemical recurrence by 15 years. However, the CSS rate approached 90% for men with pathologic organ-confined disease. Higher pathologic Gleason sum 9-10 and seminal vesicle and lymph node involvement were independent predictors of worse CSS.

Objectives Inguinal hernias occur in 15% of men within 1 to 2 years after radical retropubic prostatectomy (RRP). This suggests that many of these hernias may have been present at surgery, but not diagnosed. Beginning in September 2001, all patients undergoing RRP were carefully examined intraoperatively for the presence of a hernia or a dilated internal inguinal ring. In this study we define the frequency of inguinal hernias detected at RRP and the durability of repair. Methods Between September 2001 and December 2004, 430 patients underwent RRP by one surgeon. Hernias, detected in 142 men (33%), were repaired preperitoneally: direct hernias were repaired with mesh and indirect hernias with 2-0 Prolene suture. The patients were followed up for an average of 19 months (range 9 to 36). Information on postoperative hernia status was available for 315 men (73.3%). Results Of the 430 patients, 142 (33%) had hernias repaired at RRP. Of these hernias, 32% were right sided, 28% left sided, and 40% bilateral; 34% were direct hernias and 66% indirect. Of the 142 patients who underwent intraoperative hernia repair, 95 (67%) had follow-up data, and 5 (5.3%) of that group developed a hernia postoperatively. None of the hernias repaired at RRP recurred. Recurrent hernias on the side of the repair occurred in 3.1%. Conclusions Incidental inguinal hernias were commonly found (33%) at RRP. Two thirds of the defects detected were indirect. Clinical recurrence after repair was rare.

Objectives To determine whether a subfascial continuous infusion of local anesthetic in patients undergoing radical retropubic prostatectomy would result in a reduction in postoperative opioid requirements and an improvement in pain scores. Methods This was a prospective, double-blind, placebo-controlled, randomized trial in patients undergoing elective radical retropubic prostatectomy. A small catheter was placed subfascially at the end of surgery and attached to an elastomeric pump that administered either 0.5% bupivacaine or normal saline into the wound at a rate of 2 mL/hr until discharge on postoperative day 3. The outcomes assessed included the dosage of hydromorphone used by a patient-controlled analgesic system, a visual analog scale (VAS) for pain at rest and with activity, a VAS of nausea, and length of hospital stay. Results A total of 100 patients were successfully randomized, with all patients completing the protocol. No differences were found between the groups with regard to VAS pain at rest, VAS pain with activity, intravenous or oral analgesic consumption, or VAS nausea scores. Conclusions Continuous subfascial infusion of local anesthetic did not result in a postoperative reduction in opioid requirements or an improvement in pain scores in patients undergoing radical retropubic prostatectomy.

Objectives To determine whether postoperative methylprednisolone improves the recovery of sexual function after nerve-sparing radical retropubic prostatectomy. Methods We randomized men undergoing bilateral nerve-sparing radical retropubic prostatectomy by a single surgeon to receive 6 days of placebo or methylprednisolone beginning on postoperative day 1. At 3, 6, and 12 months postoperatively, we assessed potency with the abbreviated International Index of Erectile Function questionnaire and urinary continence with participant-reported pad use. We used the chi-square test, Fisher’s exact test, and the two-sample t test with equal variances for comparisons between study groups. Results No operative complications occurred and 70 (100%) of 70 participants experienced normal wound healing. The odds of being potent for participants who received methylprednisolone (n = 34) compared with those who received placebo (n = 36) did not significantly differ at 3 (odds ratio 0.29, 95% confidence interval 0.08 to 1.05), 6 (odds ratio 0.63, 95% confidence interval 0.17 to 2.4), or 12 (odds ratio 1.18, 95% confidence interval 0.29 to 4.8) months. The mean International Index of Erectile Function scores did not significantly differ at 3 ( P = 0.08), 6 ( P = 0.50), or 12 ( P = 0.71) months. At 12 months, 74% of the methylprednisolone and 71% of the placebo participants were potent ( P = 0.8). The proportions of participants who were continent did not differ significantly at 3 ( P = 0.89), 6 ( P = 0.25), or 12 ( P = 0.49) months. At 12 months, 96% of the methylprednisolone and 100% of the placebo participants were continent. Conclusions At doses sufficient to produce a systemic anti-inflammatory effect, postoperative methylprednisolone was not associated with improved potency at up to 12 months after bilateral nerve-sparing radical retropubic prostatectomy in men 40 to 60 years old.

Introduction Our institution previously described a surgical technique for preservation of accessory pudendal arteries at radical retropubic prostatectomy. Since then, we have expanded our experience. We now report our refinements in the surgical technique, illustrated with video, and the influence of accessory artery preservation on the recovery of sexual function after radical retropubic prostatectomy (RRP). Technical considerations Between 1987 and 2003, 2399 potent men underwent RRP. Of the 2399 men, 84 (4%) were identified with accessory pudendal arteries. Of the 84 men, 52, who underwent bilateral nerve-sparing surgery, were available for evaluation. We identified a control population, without accessory pudendal arteries, who were matched for age, stage, and neurovascular bundle status. Potency was defined as the ability to achieve unassisted intercourse with or without the use of sildenafil. In a Cox proportional hazards model, the effect of artery preservation increased the likelihood of potency more than twofold (relative risk 2.65; 95% confidence interval 1.11 to 6.32; P = 0.028). Kaplan-Meier analysis showed a significantly shorter median time to regain potency among those with artery preservation, 6 versus 12 months ( P = 0.020). Conclusions Preservation of accessory pudendal arteries may favorably influence the recovery of sexual function and interval to recovery after RRP.

Objectives To evaluate familial aggregation and the mode of inheritance of bothersome benign prostatic hyperplasia (BPH). Methods During an extension of the North American Finasteride Trial, 301 of 895 patients and 158 spousal controls completed a family history questionnaire. Segregation analysis was performed to examine the mode of inheritance in first-degree relatives of the 301 probands. Results The lifetime cumulative probability of bothersome BPH was similar in relatives of those with BPH (0.35; 95% confidence interval [CI] 0.28 to 0.44) and spousal controls (0.36; 95% CI 0.22 to 0.56), but the age of onset was significantly earlier in relatives of cases than controls (P = 0.001). Fathers of those with BPH had a significantly elevated risk of bothersome BPH (unadjusted odds ratio [OR] 2.1; 95% CI 1.2 to 3.8) and brothers had a significantly elevated risk of both bothersome BPH (OR 3.5; 95% CI 1.7 to 7.3) and transurethral resection of the prostate (OR 3.6; 95% CI 1.4 to 8.8). After adjusting for family size, the risk of bothersome BPH increased approximately twofold with each additional affected first-degree relative (0 relatives, OR 1.0; 1 relative, OR 1.7; 2 relatives, OR 4.7). Segregation analysis suggested a rare autosomal codominant allele (frequency 0.0004). Conclusions These findings confirm previous findings that family history and early age of onset are associated with an increased risk of BPH and that the most likely mode of inheritance is autosomal dominant or codominant. Bothersome BPH appears to have a weaker genetic component than more restrictive definitions of hereditary BPH. Thus, linkage studies are more likely to be successful if they focus on stricter definitions of hereditary BPH (eg, early onset, large volume, strong family history) rather than symptomatic or clinical BPH.

A67-year-old white male patient with a past medical history of prostate cancer status post nervesparing radical retropubic prostatectomy, malignant fibrohistiocytoma of the left hand, and basal cell carcinoma of the ear status post resection, presented for a follow-up visit to his urologist and was found to have an increased prostate-specific antigen (PSA). The patient had initially undergone a radical prostatectomy in December 1989 when he was 60 years old. Final pathology revealed a Gleason 6 adenocarcinoma with a focus of prostatic ductal carcinoma, organ confined (pT2) with negative margins (Figs. 1A, 1B). Initial postoperative PSA was undetectable, but in 1991, it became detectable and continued to increase to 0.8 in 1994. Bone scan and imaging of the pelvis were negative for metastatic disease. The patient received radiation therapy to his prostatic bed beginning July 1994 when the patient was 65 years old. His postradiation PSA was 0.8 and initially decreased, but in January 1997, it was 2.1. The patient denied any weight loss, fevers or chills, chest pain or shortness of breath, abdominal pain, bone pain, increased urinary frequency, urgency, or hesitancy, dysuria, or hematuria. He was having regular bowel movements. He was a lifetime nonsmoker. On examination, the patient was afebrile and his vital signs were stable. He was alert and generally appeared well. He had no cervical or axillary adenopathy. Lungs were clear to auscultation bilaterally. His abdomen was soft, nontender, and nondistended. He had a well-healed midline surgical scar. Rectal examination showed no palpable nodularity in the prostatic bed and good sphincter tone. Extremities were warm and well-perfused without edema, clubbing, or cyanosis. His laboratory test

Objectives To evaluate the influence of preoperative prostate-specific antigen (PSA), biopsy Gleason sum, and prostate biopsy quantitative histologic findings on the probability of biochemical failure in an attempt to identify criteria to substratify Stage T1c prostate cancer more accurately. Methods We reviewed the records of 1149 patients who underwent prostatectomy for T1c disease between 1988 and 2000. Biochemical recurrence (PSA 0.2 ng/mL or greater) defined the endpoint in this study. Recursive partitioning analysis was used to establish cutpoints for preoperative PSA level, biopsy Gleason sum, number of positive biopsy cores, and maximal percentage of any single biopsy core involved with cancer. These cutoff values were then evaluated using Kaplan-Meier estimations to determine the probability of remaining biochemically recurrence free. Results Using a PSA cutpoint of 10 ng/mL or a biopsy Gleason sum of 7, two groups of patients were identified (T1cI and T1cII). The rate of freedom from PSA recurrence at 3, 5, and 10 years after surgery for T1cI was 98%, 96%, and 96%, respectively, and for T1cII was 86%, 83%, and 73%, respectively (P

Introduction. Although there is no evidence that the reconstructed bladder neck actively contributes to post-radical prostatectomy continence, we set out to determine whether buttressing sutures, which prevent the bladder neck from pulling open as the bladder fills, would result in the earlier return of urinary control. Technical Considerations. Forty-five men (mean age 57 years, range 37 to 67) with clinical localized prostate cancer underwent anatomic radical retropubic prostatectomy with standard tennis racket bladder neck reconstruction. The bladder neck was then intussuscepted using two 2-0 Maxon Lembert sutures placed lateral and posterior to the reconstructed bladder neck. Filling of the bladder with saline at this point revealed little leakage. Patient-reported continence at 3 months was compared with the published outcome of 64 men using the same quality-of-life instrument (the UCLA Prostate Cancer Index). At 3 months, 82% of men who underwent intussusception of the bladder neck were continent (no pad/dry pad) compared with 54% in our prior report ( P = 0.0035). The occurrence of bladder neck contracture was similar: 7% versus 5%. Conclusions. Intussusception of the bladder neck led to a significant improvement in urinary control at 3 months postoperatively. Longer follow-up will be necessary to determine whether this approach may eliminate the 2% probability of long-term significant problems with urinary control.

Objectives. To investigate the influence of biopsy perineural invasion (PNI) on long-term prostate-specific antigen recurrence rates, final pathologic stage, and surgical margin status of men treated with radical prostatectomy. Radical prostatectomy offers the best chance for surgical cure when performed for organ-confined disease. However, the histologic identification of PNI on prostate biopsy has been associated with a decreased likelihood of pathologically organ-confined disease. Methods. Seventy-eight men with histologic evidence of PNI on biopsy underwent radical prostatectomy by a single surgeon between April 1984 and February 1995 and were compared with 78 contemporary matched (biopsy Gleason score, prostate-specific antigen level, clinical stage, age) controls without PNI. Biochemical disease-free survival and pathologic findings were compared. Results. After a mean follow-up of 7.05 ± 2.2 years and 7.88 ± 2.7 years (P = 0.04) for patients with biopsy PNI and controls, respectively, no significant difference in the long-term prostate-specific antigen recurrence rates was observed (P = 0.13). The final Gleason score and pathologic staging were also similar in this matched cohort. Although the numbers of neurovascular bundles resected were comparable between the groups, no difference was found in the rate of positive surgical margins identified (13% versus 10%, P = 0.62). Conclusions. We were unable to show that PNI on needle biopsy influences long-term tumor-free survival.

Objectives. To evaluate the influence of isolated, histologically identified capsular incision (CI) (exposure of benign or malignant glands to the inked surgical margin in the setting of organ-confined disease) on disease progression after anatomic radical retropubic prostatectomy (RRP) for clinically localized prostate cancer. Methods. Between March 1993 and September 1999, 4747 men underwent RRP at the Johns Hopkins Hospital; 107 men (2.3%) were diagnosed with CI in otherwise organ-confined disease; 92 (86%) had at least 6 months (mean 30) of follow-up. We matched these CI cases (based on surgeon, age, clinical stage, final pathologic Gleason grade, and preoperative serum prostate-specific antigen level) one-for-one with controls in three additional pathologically defined groups and compared the freedom from disease progression (prostate-specific antigen level greater than 0.2 ng/mL and/or local palpable recurrence) after RRP. Results. The actuarial 3-year likelihood of freedom from disease progression was 87.8% for the CI group, 96.4% for men with organ-confined disease (P = 0.10), 91.3% for men with extraprostatic extension and negative surgical margins (P = 0.99), and 73.9% for men with positive surgical margins resulting from extraprostatic extension (P

Objectives. To determine the significance of Gleason scores 3+4 (GS3+4) versus 4+3 (GS4+3) with respect to biochemical recurrence in a retrospective review of a series of men with clinically localized prostate cancer who underwent radical retropubic prostatectomy (RRP) and to develop and test an artificial neural network (ANN) to predict the biochemical recurrence after surgery for this group of men using the pathologic and clinical data. Methods. From 1982 to 1998, 600 men had pathologic Gleason score 7 disease without lymph node or seminal vesicle involvement. We analyzed the freedom from biochemical (prostate-specific antigen) progression after RRP on 564 of these men on the basis of their GS3+4 versus GS4+3 (Gleason 7) status. The Cox proportional hazards model was used to determine the importance of Gleason 7 status as an independent predictor of progression. In addition, an ANN was developed using randomly selected training and validation sets for predicting biochemical recurrence at 3 or 5 years. Different input variable subsets, with or without Gleason 7 status, were compared for the ability of the ANN to maximize the prediction of progression. Standard logistic regression was used concurrently on the same random patient population sets to calculate progression risk. Results. A significant recurrence-free survival advantage was found in men who underwent RRP for GS3+4 compared with those with GS4+3 disease (P

Objectives. To determine the clinical significance of Gleason score 3+4 versus 4+3 on radical prostatectomy. Methods. Of 2390 men who underwent radical prostatectomy by a single surgeon, 570 had Gleason score 7 tumors without lymph node metastasis, seminal vesicle invasion, or tertiary Gleason pattern 5. Patients were evaluated for biochemical recurrence (prostate-specific antigen progression) and distant metastases. Results. Eighty percent of patients had Gleason score 3+4, 20% had 4+3. The rate of established extraprostatic extension at radical prostatectomy for Gleason score 3+4 and 4+3 tumors was 38.2% and 52.7%, respectively (P = 0.008). With a mean follow-up of 4.6 years for men without progression, Gleason score 4+3 tumors had an increased risk of progression independent of stage and margin status (P

Objectives. Various methods have been proposed to increase the specificity of prostate-specific antigen (PSA), including age-specific PSA reference ranges, PSA density (PSAD), and percent free PSA (%fPSA). In this multicenter study, we compared these methods for their utility in cancer detection and their ability to predict pathologic stage after radical prostatectomy in patients with clinically localized, Stage T1c cancer. Methods. Seven hundred seventy-three men (379 with prostate cancer, 394 with benign prostatic disease), 50 to 75 years old, from seven medical centers were enrolled in this prospective blinded study. All subjects had a palpably benign prostate, PSA 4.0 to 10.0 ng/mL, and a histologically confirmed diagnosis. Hybritech’s Tandem PSA and free PSA assays were used. Results. %fPSA and age-specific PSA cutoffs enhanced PSA specificity for cancer detection, but %fPSA maintained significantly higher sensitivities. Age-specific PSA cutoffs missed 20% to 60% of cancers in men older than 60 years of age. %fPSA and PSAD performed equally well for detection (95% sensitivity) if cutoffs of 25% fPSA or 0.078 PSAD were used. The commonly used PSAD cutoff of 0.15 detected only 59% of cancers. %fPSA and PSAD also produced similar results for prediction of the post-radical prostatectomy pathologic stage. Patients with cancer with higher %fPSA values (greater than 15%) or lower PSAD values (0.15 or less) tended to have less aggressive disease. Conclusions. The results of this study demonstrated that cancer detection (sensitivity) is significantly higher with %fPSA than with age-specific PSA reference ranges. %fPSA and PSAD provide comparable results, suggesting that %fPSA may be used in place of PSAD for biopsy decisions and in algorithms for prediction of less aggressive tumors since the determination of %fPSA does not require ultrasound.

In predominately white populations, measurement of the percentage of free prostate-specific antigen (%fPSA) has been shown to enhance the specificity of total PSA testing for prostate cancer while maintaining high sensitivity and to aid in prostate cancer staging. This study evaluated whether the %fPSA cutoff that maintained a 95% sensitivity in a white population yielded the same sensitivity and specificity in a black population and whether %fPSA was useful in predicting postoperative pathologic features in blacks.We evaluated 647 white and 79 black men, prospectively enrolled at prostate cancer screening and surgical referral centers. Subjects were 50 to 75 years old with digital rectal examination findings that were not suspicious for prostate cancer and total PSA values between 4.0 and 10.0 ng/mL. All had undergone needle biopsy of the prostate. Hybritech's Tandem total and free PSA assays were used.Ninety-five percent sensitivity was attained with a %fPSA cutoff of 25% in both races. Use of this cutoff could have avoided unnecessary biopsies in 20% of white and 17% of black subjects (P = 0.69). In receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) for %fPSA was significantly higher than for total PSA in both blacks (0.76 versus 0.56, P0.01) and whites (0.70 versus 0.54, P0.001). In both races, higher %fPSA values indicated a lower risk of cancer and also predicted favorable pathologic features in radical prostatectomy specimens.A 25% fPSA cutoff detected 95% of cancers and reduced unnecessary biopsies in both races. Higher %fPSA values were associated with favorable postoperative histopathologic findings in both races.

Objectives. After radical prostatectomy, the rates for recovery of urinary continence and sexual function reported by experienced surgeons are much higher than the patient-reported outcomes from other centers. It is uncertain whether this represents differences in surgical technique or in the collection of data. This study was performed to determine patient-reported rates of continence and potency after radical prostatectomy performed by an experienced surgeon at a high-volume referral center for the treatment of localized prostate cancer. Methods. Sixty-four men with localized prostate cancer who were potent preoperatively and who had sexual partners underwent anatomic radical prostatectomy between March 1997 and January 1998. A validated disease-targeted quality-of-life survey that assesses function and bother in two organ systems (urinary and sexual) was administered preoperatively and at 3, 6, 12, and 18 months postoperatively. Results. Urinary continence, which was defined as wearing no pads, gradually improved during the first 12 months after surgery, and at 12 and 18 months, 93% of the patients were dry. Throughout the study, 93% to 98% of the patients characterized their urinary bother as none or small. Potency, defined as the ability to have unassisted intercourse with or without the use of sildenafil, improved gradually, and by 18 months, 86% of patients were potent and 84% considered sexual bother as none or small. Although one third of patients at 18 months were using sildenafil intermittently, only 2 patients were not able to have intercourse without its use. Conclusions. Patient-reported rates of continence and potency after radical prostatectomy performed by an experienced surgeon are high.

Objectives. To evaluate the relative efficacy of brachytherapy to radical prostatectomy, we compared biochemical progression rates from a published series of men who underwent iodine 125 ( 125 I) interstitial radiotherapy for localized prostate cancer to a similar group of men who underwent anatomic radical prostatectomy using appropriate end points. Methods. Seventy-six men who underwent anatomic radical prostatectomy between 1988 and 1990 were carefully matched for Gleason score and clinical stage to a recently reported contemporary series of patients treated at another institution with 125 I brachytherapy without adjuvant treatment. The definition of biochemical progression was a serum PSA level greater than 0.2 ng/mL after anatomic radical prostatectomy and greater than 0.5 ng/mL for brachytherapy-treated patients. Results. The 7-year actuarial PSA progression-free survival following anatomic radical prostatectomy was 97.8% (95% confidence interval [CI], 85.6% to 99.7%) for this group of men selected to match the brachytherapy group, compared to 79% (95% CI not published) for men treated with 125 I interstitial radiotherapy. Conclusions. Using comparative end points for biochemical-free progression, failure rates may be higher following 125 I interstitial radiotherapy compared to anatomic radical prostatectomy. These data provide a better comparison of biochemical progression than previously published studies and emphasize the need for caution in interpreting the relative efficacy of brachytherapy in controlling localized prostate cancer.

Objectives There is no consensus on the management of Stage D1 prostate cancer. The literature suggests that radical prostatectomy, as compared with pelvic lymphadenectomy (PLND) alone, may extend survival. Despite evidence that lymph node tumor burden influences cancer survival, few groups of researchers have controlled for this variable when comparing management strategies. We performed a study that was case-controlled for nodal tumor burden to determine if a survival advantage exists for radical prostatectomy. Methods Of 168 men with Stage D1 disease diagnosed between 1983 and 1995, 127 underwent pelvic lymphadenectomy and radical retropubic prostatectomy (PLND/RRP) and 41 underwent PLND alone. Clinical charts were reviewed for follow-up, and lymph node tumor burden was assessed by volume of nodal metastases and the percentage of positive nodes sampled. Adjuvant treatment was based on the surgeon's preference and clinical situation. Nineteen patients from each group were matched for age, PSA, Gleason score, clinical stage, follow-up, and nodal tumor burden. Results Comparison of the non-case-controlled PLND/RRP and PLND groups showed no differences in age, prostate-specific antigen level, Gleason score, clinical stage, or follow-up. The nodal tumor burden was greater for the PLND group (P = 0.001). The 10-year cancer-specific survival rates for the PLND/RRP and PLND groups were statistically different (P = 0.006). In the case-controlled group, the results were similar for cancer-specific survival at 10 years (56% and 34%, respectively; P = 0.09). Conclusions These data suggest that in Stage D1 prostate cancer, a trend toward a statistical difference in survival may exist for radical prostatectomy as compared with conservative treatment. Further case-controlled and prospective randomized studies are needed to verify these results.

Objective To evaluate the impact of an extended pelvic lymph node (LN) dissection (EPLND) on the oncologic outcomes of men with LN-positive prostate cancer. Methods Patients were identified who underwent an open radical prostatectomy by one of two surgeons at the Johns Hopkins Hospital between 1992 and 2003. The first surgeon routinely performed a limited pelvic LN dissection (LPLND), whereas the second performed an EPLND. Men with positive LNs from each cohort were compared for differences in oncologic outcomes. Results Positive LNs were found in 94 men (2.2%), 21 (22.3%) with an LPLND and 73 (77.7%) with an EPLND. On average, LPLND and EPLND yielded 11.4 and 14.6 nodes, respectively ( P = .022). The two groups were similar in terms of the number of positive LNs (1.4 vs 1.8, P = .223) and the proportion of patients with P = .300). At a median follow-up of 10.5 years, patients who underwent an EPLND had superior oncologic outcomes compared with the LPLND group: 5-year biochemical recurrence-free survival of 30.1% vs 7.1% ( P = .018), 10-year metastasis-free survival of 62.2% vs 22.2% ( P = .035), and 10-year cancer-specific survival of 83.6% vs 52.6% ( P = .199). This analysis demonstrated an augmented improvement in biochemical recurrence-free survival in men with Conclusion In addition to affording valuable staging information, an EPLND may confer a therapeutic benefit to patients found to have positive LNs at the time of radical prostatectomy.

The factors that determine tumor aggressiveness are multifactorial: age, stage, and grade. Even a well differentiated tumor in a young patient may be aggressive someday because of genetic drift and tumor heterogeneity. In a recent review of 826 favorably selected cases managed with conservative therapy, metastatic disease had developed in 19% with grade I tumors, 42% with grade II, and 74% with grade III at 10 years. Recognizing that20% of men present with grade I disease, most prostate cancers are a threat to life in men who are going to live longer than 10 years. On the other hand, some tumors at presentation are too far advanced to cure. To improve the accuracy of preoperative staging in identifying these cases, we have developed nomograms based upon clinical stage, grade, and serum prostate-specific antigen (PSA). Traditionally, patients with high-grade tumors (Gleason 8-10) were never considered candidates for radical prostatectomy because of their poor expectancy for long-term survival. However, with improvements in the staging of prostate cancer and with a reduction in the morbidity of radical prostatectomy, a subset of these patients are potential candidates for curative therapy. We have recently studied the clinical outcome of 72 men with Gleason scores of 8-10 on needle biopsies who presented with clinically localized disease (9 T1c, 22 T2a, 17 T2b, 13 T2c, and 11 T3a). Of the 63 men who underwent radical prostatectomy, 46 (68%) had negative lymph nodes; nine did not undergo surgery because of positive lymph nodes identified from frozen section. The actuarial likelihood of an undetectable serum PSA at 5 years was 43% for men with negative lymph nodes and 45% for men with organ-confined disease. Thus, with proper evaluation, some men with even the most aggressive tumors can be cured by surgery if their pelvic lymph nodes are negative.

Objectives To evaluate short-term and long-term variability between prostate-specific antigen (PSA) measurements to determine the most appropriate PSA sampling interval and rate of PSA change (PSA velocity) to distinguish between men with and without prostate cancer. Methods Retrospective study of PSA variability and PSA velocity in three groups of men without a diagnosis of prostate cancer and PSA levels less than 10 ng/mL: 56 men with a histologic diagnosis of benign prostatic hyperplasia (BPH; histologic BPH group) and 527 men with no history of cancer (noncancer group) who were part of the Baltimore Longitudinal Study of Aging and had PSA sampled at 2-year intervals (long-term), and 223 men with a clinical diagnosis of BPH (clinical BPH group) who had PSA sampled at 3-month intervals (short-term). PSA variability (deviation between consecutive measurements) and PSA velocity based on both two consecutive measurements and three consecutive measurements (average velocity) were calculated for each study group. Results PSA velocity is the deviation in PSA measurements relative to the elapsed time between the measurements. Because the variability in PSA between measurements was similar for the groups, the major factors that influenced PSA velocity were the sampling interval between PSA measurements, and to a lesser extent, the number of repeat PSA measurements. The 99th percentile for PSA velocity was 0.7 (histologic BPH group) and 0.75 ng/mL per year for the noncancer group when three measurements with a 24-month PSA sampling interval were used. However, the 99th percentile for PSA velocity was 5.8 and 2.4 ng/mL per year when three measurements with 3-month and 6-month PSA sampling intervals were used. Using three measurements, the percentage of subjects with a PSA velocity more than 0.75 ng/mL per year was 1 % for the groups with a 24-month PSA sampling interval and 28% and 17% for 3-month and 6-month PSA sampling intervals, respectively. The 99th percentile for PSA velocity and the percentage of subjects with a PSA velocity more than 0.75 ng/mL per year was higher using two measurements compared to three measurements regardless of PSA sampling interval. Conclusions PSA velocity is inversely related to the interval between PSA measurements. A PSA velocity more than 0.75 ng/mL per year is useful in distinguishing between men with and without prostate cancer when: (1) velocity is based on three consecutive measurements; and (2) PSA is sampled long-term (2 years) but not short-term (3 to 6 months).

OBJECTIVES To critically evaluate the perioperative management of rectal injury during radical prostatectomy. METHODS Rectal injuries were identified from the departmental morbidity and mortality records and radical prostatectomy databases. The electronic patient records were reviewed for management and outcomes. RESULTS From January 1997 to August 2007, 11 452 men underwent radical prostatectomy. Of these men, 10 183 underwent radical retropubic prostatectomy (RRP) and 1269, laparoscopic retropubic prostatectomy (LRP) with or without robotic assistance. Rectal injury occurred in 18 men-12 in the RRP group (0.12%) and 6 in the LRP group (0.47%). Of these rectal injuries, 16 were recognized intraoperatively and primarily repaired in multiple layers without a diverting colostomy. A pedicle of omentum was used as an interposing layer in 4 of these cases. Despite primary repair, 2 patients without omental interposition developed a rectourethral fistula. In 1 man in the RRP group, the fistula closed with prolonged catheterization (9 weeks). In the other patient, in the LRP group, the fistula persisted; thus, a diverting colostomy was performed. Eventually, a transrectal advancement flap was required. Two rectal injuries (1 each in the RRP and LRP groups) were unrecognized during radical prostatectomy but were discovered within 4 days. Despite conservative management, the rectourethral fistulas persisted in both men, requiring subsequent repair with a transrectal advancement flap. CONCLUSIONS Rectal injury is an infrequent complication of radical prostatectomy. When recognized intraoperatively and primarily repaired, rectourethral fistula was prevented in 87.5% of men. Primary repair performed with vascularized tissue interposition prevented rectourethral fistula development. In men with unrecognized rectal injury, the rectourethral fistula tended to persist and eventually required delayed surgical repair.

OBJECTIVES The new American Society for Therapeutic Radiology and Oncology/Radiation Therapy Oncology Group consensus definition of biochemical failure after radiotherapy for prostate cancer is defined as a prostate-specific antigen level at or greater than the absolute nadir PSA level plus 2 ng/mL. Because this definition inevitably will be used to compare cancer control rates after radiotherapy to those after surgery, this study examined the effect of this comparison. METHODS We reviewed the data from 2570 men who had undergone radical prostatectomy from 1985 to 2004. Biochemical failure was defined as any measurable PSA level of 0.2 ng/mL or greater. We evaluated how the nadir+2 definition affected the failure rate when applied to this series. RESULTS The actuarial 5, 10, and 15-year biochemical recurrence-free survival probability with failure defined as a PSA level of 0.2 ng/mL or more and a PSA level of 2 ng/mL or more was 88.6%, 81.2%, and 78.1% and 94.6%, 89.4%, and 84.3%, respectively (P

OBJECTIVES Men with pathologically organ-confined, Gleason score 6 or less prostate cancer are considered to have an excellent prognosis after surgery as definitive monotherapy. We determined the incidence of biochemical recurrence (BR), local recurrence (LR), distant metastasis (DM), and prostate cancer-specific mortality (PCSM) among this low-risk cohort. METHODS A retrospective search of our radical prostatectomy database identified 6081 men with pathologically organ-confined (pT2), Gleason score 6 or less prostate cancer treated from 1983 to 2005. Of these, 2551 (42%) had adequate follow-up information and were assessed for BR, LR, DM, and PCSM. The pathologic specimens of men with disease progression were reevaluated by an experienced genitourinary pathologist, and the patients with disease that was upgraded or upstaged (n = 25) were excluded from additional analysis, resulting in a final study cohort of 2526. The actuarial probabilities of BR and LR were estimated using the Kaplan-Meier method. RESULTS With a median follow-up of 5.0 years (range 2 to 22), BR occurred in 13 patients (0.5%). The 5, 10, and 15-year actuarial probability of BR was 0.3%, 0.9%, and 1.3%, respectively. Five patients (0.2%) developed LR, four of whom received salvage radiotherapy with a subsequently undetectable prostate-specific antigen level. The 5, 10, and 15-year actuarial probability of LR was 0.1%, 0.5%, and 0.5%, respectively. No DM or PCSM occurred. CONCLUSIONS With postoperative follow-up for more than 2500 patients with pathologically organ-confined, Gleason score 6 or less prostate cancer, BR and LR after radical prostatectomy were extremely rare, and no patients experienced DM or PCSM.

Objectives. Rates of prostate cancer in Kingston, Jamaica are extremely high (occurring in more than 300 men out of 100,000 in 1989 to 1993). This article addresses the familial aggregation of prostate cancer in Jamaica. Early evidence for familial prostate cancer was found in the Utah Mormon population. Increased risk of prostate cancer in men with a family history of prostate cancer has been consistently observed in subsequent studies. There have been few studies, however, involving black men, who are known to have an overall higher risk of developing prostate cancer. Methods. Two hundred sixty-three patients with prostate cancer documented by histology were studied. Two hundred sixty-three age-matched control patients were used for comparison. Extensive pedigrees were obtained for both patients with cancer and controls. Data on other malignancies including lung, breast, colon, stomach, and uterine were also collected. Results. The patients with cancer and the controls were comparable with respect to age and family size. Thirty patients with cancer had a first degree relative (ie, brother, father, or son) with prostate cancer compared to 15 controls. The odds ratio is 2.1 (95% confidence interval 1.1 to 4.4). Nine patients with cancer had a second degree relative (ie, grandfather, grandson, or uncle) affected compared to 3 controls. The odds ratio is 3.1 (95% confidence interval 0.8 to 17.8). There was no statistically significant difference in the rates of any of the other cancers studied. Conclusions. Familial aggregation of prostate cancer is clearly evident in black Jamaican men. A man with one first degree relative with prostate cancer is twice as likely as the general population to develop prostate cancer. In addition, there may be a statistical difference in the risk of developing prostate cancer if an individual has one second degree relative affected.

Objectives To update the 2001 “Partin tables” with a contemporary patient cohort and revised variable categorization, correcting for the effects of stage migration. Methods We analyzed 5730 men treated with prostatectomy (without neoadjuvant therapy) between 2000 and 2005 at the Johns Hopkins Hospital. Average age was 57 years. Multivariable logistic regression was used to estimate the probability of organ-confined disease, extraprostatic extension, seminal vesicle involvement, or lymph node involvement. Predictor variables included preoperative prostate-specific antigen (PSA) level (0 to 2.5, 2.6 to 4.0, 4.1 to 6.0, 6.1 to 10.0, and greater than 10.0 ng/mL), clinical stage (T1c, T2a, and T2b/T2c), and biopsy Gleason score (5 to 6, 3 + 4 = 7, 4 + 3 = 7, or 8 to 10). Bootstrap resampling was used to generate 95% confidence intervals for predicted probabilities. Results Seventy-seven percent of patients had T1c, 76% had Gleason score 5 to 6, 80% had a PSA level between 2.5 and 10.0 ng/mL, and 73% had organ-confined disease. Nomograms were developed for the predicted probability of pathologically organ-confined disease, extraprostatic extension, seminal vesicle invasion, or lymph node involvement. The risk of non-organ-confined disease increased with increases in any individual prognostic factor. The dramatic decrease in clinical stage T2c compared with the patient series used in the previous models resulted in T2b and T2c being combined as a single predictor in the nomogram. Conclusions These updated “Partin tables” were generated to reflect trends in presentation and pathologic stage for men diagnosed with clinically localized prostate cancer at our institution. Clinicians and patients can use these nomograms to help make important decisions regarding management of prostate cancer.

Objectives To examine the relationship among needle biopsy primary grade, prostatectomy grade, and postprostatectomy biochemical recurrence among men with Gleason score 7 disease. Methods We identified 320 men with Gleason score 7 tumors on prostate biopsy treated with radical prostatectomy between 1991 and 2001 by a single surgeon. None of these patients had received neoadjuvant or adjuvant hormonal therapy or radiotherapy. The chi-square test and Kaplan-Meier method were used to evaluate the correlation among biopsy Gleason score, prostatectomy Gleason score, and biochemical recurrence. Results A total of 252 (79%) and 68 (21%) men had primary Gleason pattern 3 and 4 identified on needle biopsy, respectively. Of the patients with Gleason pattern 3 + 4 tumors on biopsy, 24% were upgraded to primary pattern 4 or more on final pathologic analysis. Of the patients with Gleason pattern 4 + 3 tumors on biopsy, 47% were downgraded to primary pattern 3 or less on final pathologic analysis. The actuarial risk of biochemical prostate-specific antigen recurrence was significantly lower among patients with Gleason pattern 4 + 3 on biopsy, if the prostatectomy Gleason score was downgraded to 3 + 4 or less ( P = 0.03). Conclusions Approximately 47% of men with a diagnosis of Gleason pattern 4 + 3 on needle biopsy are downgraded at radical prostatectomy and will have biochemical prostate-specific antigen recurrence-free outcomes similar to patients originally diagnosed with Gleason pattern 3 + 4 adenocarcinoma. This group of patients may benefit from definitive treatment such as radical prostatectomy for management of their disease.

Objectives To identify the prognostic significance of positive bladder neck margin as the sole positive margin after radical retropubic prostatectomy for treatment of prostate cancer. Methods We retrospectively analyzed the data from patients who underwent radical retropubic prostatectomy at Johns Hopkins Hospital between 1984 and 2001. Of 164 patients with positive margins, 38 had a positive margin only at the bladder neck margin and 126 had a positive margin at one or more locations separate from the bladder neck margin. Results Kaplan-Meier analyses showed that patients with a positive bladder neck margin had a greater biochemical progression risk than patients with positive margins at one or more locations other than the bladder neck margin. The 5-year actuarial risk of progression in men with positive and negative bladder neck margins was 69.8% and 33.0%, respectively. A positive bladder neck margin was statistically an independently significant predictor of progression ( P = 0.001), along with the prostatectomy Gleason score ( P = 0.0001) in the multivariate analysis. The hazard ratio for predicting progression for postoperative Gleason score and bladder neck positivity was 2.1 and 2.5, respectively. Serum prostate-specific antigen values, clinical stage, age, and the percentage of tumor at the bladder neck margin were not predictors of progression in either univariate or multivariate analysis. Conclusions Patients with a positive bladder neck margin as the sole positive margin at radical retropubic prostatectomy have a greater risk of biochemical progression than patients with one or more positive margins at other locations, although not as adverse as the risk reported for those with Stage T4 disease.

Objectives The Partin tables provide pretreatment information regarding the probability of various pathologic stages (eg, organ confined, extraprostatic extension, and seminal vesicle or lymph node involvement). Although the pathologic stage serves as an excellent surrogate for outcome after radical prostatectomy (RRP), many patients and physicians want to know how the predictions made from the Partin tables can be translated into long-term biochemical recurrence-free survival. In this work, we go beyond the pathologic outcomes predicted by the Partin nomograms to provide long-term biochemical recurrence-free estimates on the basis of the pathologic data obtained at RRP to help counsel patients after surgery for prostate cancer. Methods The study group comprised 1955 men treated by one surgeon with RRP and pelvic lymph node dissection for clinically localized disease (1989 to 2001). The patients were followed up for at least 1 year postoperatively, and the disease-free survival rates were determined using Kaplan-Meier analysis. Results The pathologic stages were as follows: organ confined in 57%, extraprostatic extension in 35%, seminal vesicle involvement in 4%, and lymph node involvement in 4%. The prostatectomy Gleason score distribution was as follows: 2 to 4 in 1%, 5 to 6 in 63%, 7 in 30%, and 8 to 10 in 6%. Overall, a positive surgical margin was present in 9.8%. On the basis of the prostatectomy Gleason score, pathologic stage, and surgical margin status, the probability of long-term biochemical recurrence-free survival was divided into four groups: excellent, good, moderate, and low. Conclusions These simple to use and explain risk groups can be used to predict long-term biochemical recurrence-free survival from pathologic stage data obtained at surgery or predicted from the Partin tables, along with surgical margin status and Gleason score information obtained at RRP.

To compare the cancer control in men younger than 50 years with that in older men treated with radical retropubic prostatectomy (RRP) for localized prostate cancer in a contemporary series. In the 1970s and 1980s, men younger than 50 years old represented approximately 1% of newly diagnosed prostate cancer cases. However, with the widespread use of serum prostate-specific antigen (PSA) testing and increased public awareness of prostate cancer, this figure has risen (3.7% to 4%). Previous studies, mostly carried out before the PSA era, reported conflicting data with respect to cancer control for these younger men treated with RRP.We analyzed the data from 2897 men who underwent RRP between April 1982 and September 2001. Preoperative PSA level, clinical and pathologic stage, and biochemical recurrence were compared between 341 men younger than 50 years old and 2556 men 50 years old or older. Disease-free (PSA less than 0.2 ng/mL) survival rates were compared using Kaplan-Meier analysis. Pathologic staging was compared using logistic regression analysis.Men younger than 50 years old had pathologic variables and 5, 10, and 15-year biochemical disease-free survival rates comparable to men aged 50 to 59 years (88%, 81%, and 69% versus 87%, 78%, and 71%, respectively). However, younger men had a lower incidence of extraprostatic extension (25% versus 31%; P0.02), seminal vesicle involvement (2% versus 6%; P0.03), and positive surgical margins (3% versus 9%; P0.03), a greater organ-confined disease rate (65% versus 49%; P0.0001), and a trend toward greater 5, 10, and 15-year biochemical disease-free survival rates, which did not reach statistical significance, compared with men aged 60 to 69 years (84%, 74%, and 67%, respectively; P0.09). Furthermore, younger men not only had a lower rate of extraprostatic extension (25% versus 36%; P0.001), seminal vesicle involvement (2% versus 10%; P0.001), and positive surgical margins (3% versus 9%; P0.001) and a greater organ-confined disease rate (65% versus 36%; P0.0001), they also demonstrated significantly (P0.003) greater 5, 10, and 15-year biochemical disease-free survival rates compared with men aged 70 years or older (72%, 58%, and 58%, respectively).Men diagnosed with prostate cancer who are younger than 50 years of age and are candidates for RRP tend to have a greater probability of organ-confined disease than older men. Younger men also demonstrate greater long-term cancer control rates than older men.

We have experienced the inability to remove silicone Foley catheters even after complete deflation of the balloon. This potential complication can result from cuffing of the catheter balloon. We present a description of this phenomenon and approaches for successful management of a Foley catheter that has become entrapped due to balloon cuffing.

To summarize the 6-year clinical trial data with finasteride. Benign prostatic hyperplasia is a chronic and progressive disease and therefore assessment of long-term safety and efficacy is important.The North American and International Phase III Finasteride trials enrolled symptomatic men with enlarged prostate glands. The initial 1-year placebo-controlled study was followed by a 5-year open-label extension. In total, 6-year finasteride data were available in 487 patients originally randomized to finasteride, and 5-year data were available on 238 patients originally randomized to placebo.After 6 years of treatment with finasteride 5 mg, the mean quasi-American Urological Association Symptom Score improved by 4.0 points, the median prostate volume decreased by 24%, and the mean maximal urinary flow rate increased by 2.9 mL/s (P0.001 for all parameters). Long-term finasteride treatment was well tolerated, with a low incidence of drug-related sexual adverse events occurring during the first year and even fewer occurrences during the 5-year open extension.Treatment with finasteride leads to durable improvement in urinary tract symptoms, flow rate, and prostate volume, with no increase in the prevalence of drug-related adverse events over time.

The influence of external sequential compression devices (SCD) on the development of postoperative thromboembolic events was studied in 1,300 consecutive men undergoing radical retropubic prostatectomy. Of the 784 men whose perioperative management did not involve the SCD, in 9 (1.1%) thromboembolic complications developed: 7 (0.9%) pulmonary emboli (PE), and 2 (0.3%) deep venous thrombosis (DVT). In the 516 patients with SCD prophylaxis there were 12 (2.3%) thromboembolic complications: 9 (1.7%) PE, and 3 (0.6%) DVT. In patients with SCD prophylaxis, the delay from the time of surgery to the onset of thromboembolic symptoms averaged 20 +/- 12 days, and all but 1 patient suffered the complication while an outpatient; this was significantly longer than in men without SCD (11 +/- 5 days; p < 0.05). This delay in thromboembolic events was the only benefit we could demonstrate with SCD. Recognizing that most thromboembolic complications occur after discharge, new strategies for prophylaxis may be needed during this period, and patients should be well informed about the signs and symptoms of PE and DVT to avoid a delay in diagnosis and treatment.

Objectives. We previously presented nomograms combining preoperative serum prostate-specific antigen (PSA), clinical (TNM) stage, and biopsy Gleason score to provide the likelihood of various final pathologic stages at radical retropubic prostatectomy. The data for the original nomograms were collected from men treated between 1982 and 1996. During the past 10 years, the stage at presentation has shifted, with more men presenting with Stage T1c, Gleason score 5 to 6, and serum PSA levels less than 10.0 ng/mL. In this work, we update the “Partin Tables” with a more contemporary cohort of men treated since 1994 and with revised PSA and Gleason categories. Methods. Multinomial log-linear regression analysis was used to estimate the likelihood of organ-confined disease, extraprostatic extension, seminal vesicle or lymph nodal status from the preoperative PSA stratified as 0 to 2.5, 2.6 to 4.0, 4.1 to 6.0, 6.1 to 10.0, and greater than 10 ng/mL, clinical (AJCC-TNM, 1992) stage (T1c, T2a, T2b, or T2c), and biopsy Gleason score stratified as 2 to 4, 5 to 6, 3 + 4 = 7, 4 + 3 = 7, or 8 to 10 among 5079 men treated with prostatectomy (without neoadjuvant therapy) between 1994 and 2000 at Johns Hopkins Hospital. The average age was 58 years. Results. In this cohort, more than 60% had T1c, more than 75% had Gleason score of 6, more than 70% had PSA greater than 2.5 and less than 10.0 ng/mL, and more than 60% had organ-confined disease. Nomograms of the robust estimated likelihoods and 95% confidence intervals were developed from 1000 bootstrap analyses. The probability of organ-confined disease improved across the groups, and further stratification of the Gleason score and PSA level allowed better differentiation of individual patients. Conclusions. These updated “Partin Tables” were generated to reflect the trends in presentation and pathologic stage for men newly diagnosed with clinically localized prostate cancer at our institution. Clinicians can use these nomograms to counsel individual patients and help them make important decisions regarding their disease.

Objectives. To develop a model that will identify a contemporary cohort of patients at high risk of early prostate cancer recurrence (greater than 50% at 36 months) after radical retropubic prostatectomy for clinically localized disease. Data from this model will provide important information for patient selection and the design of prospective randomized trials of adjuvant therapies. Methods. Proportional hazards regression analysis was applied to two patient cohorts to develop and cross-validate a multifactorial predictive model to identify men with the highest risk of early prostate cancer recurrence. The model and validation cohorts contained 904 and 901 men, respectively, who underwent radical retropubic prostatectomy at Johns Hopkins Hospital. This model was then externally validated using a cohort of patients from the Mayo Clinic. Results. A model for weighted risk of recurrence was developed: R W ′= lymph node involvement (0/1)×1.43+ surgical margin status (0/1)×1.15+ modified Gleason score (0 to 4)×0.71+ seminal vesicle involvement (0/1)×0.51. Men with an R W ′ greater than 2.84 (9%) demonstrated a 50% biochemical recurrence rate (prostrate-specific antigen level greater than 0.2 ng/mL) at 3 years and thus were placed in the high-risk group. Kaplan-Meier analyses of biochemical recurrence-free survival demonstrated rapid deviation of the curves based on the R W ′. This model was cross-validated in the second group of patients and performed with similar results. Furthermore, similar trends were apparent when the model was externally validated on patients treated at the Mayo Clinic. Conclusions. We have developed a multivariate Cox proportional hazards model that successfully stratifies patients on the basis of their risk of early prostate cancer recurrence.

H often is it necessary to excise one or both neurovascular bundles widely at the time of radical prostatectomy and is it useful to use an interposition nerve graft in an attempt to restore sexual function in these patients? In this essay, I express my opinion about when it is necessary to excise the neurovascular bundles, how often potency recovers in patients with unilateral wide excision, and what is the value of nerve grafts.

Objectives. To determine whether needle biopsy of the posterolateral aspects of the prostate aids in prostate cancer detection. In the routine sextant biopsy strategy, the posterolateral aspects of the prostate are not sampled. Methods. Using an 18-gauge biopsy gun, we performed sextant biopsies and an additional nine needle biopsies in the pathology laboratory on 150 radical prostatectomy specimens performed for Stage T1c prostate cancer. The additional nine biopsies consisted of three midline biopsies and six (three each from the left and right) posterolaterally aimed biopsies from the apex, mid, and base regions of the gland. Significant tumors were defined as those greater than 0.5 cm3, or with a Gleason score of 7 or greater, or non-organ confined. Results. Of the 123 cases with cancer on repeated biopsy, in only 3 (2.4%) was the only cancer found in the midline biopsies. For the following analysis, we analyzed the data as if we had not done the midline biopsies. If one had performed only the routine sextant needle biopsies, in 31 (25.2%) of the 123 cases, tumor would have been missed; 20 of these tumors were significant, including 5 with extraprostatic extension. If one had performed only the more posterolateral six biopsies, in 15 cases (12.2%), tumor would have been missed; 5 of these tumors were significant, all of which were organ confined. Conclusions. Adding routine midline biopsies does not appreciably increase the detection of cancer. If one were to only perform six needle biopsies of the prostate, these biopsies should be aimed more toward the posterolateral aspect of the gland. Maximum cancer detection results from combining both routine sextant and posterolateral needle biopsies.

Objectives. Serum acid phosphatase (ACP) was once used as the marker for advanced prostate cancer. However, with the development of assays for prostate-specific antigen (PSA), a more sensitive and specific tumor marker, the use of ACP has diminished. We investigated the prognostic value of preoperative serum ACP in predicting prognosis for men with localized prostate cancer following radical retropubic prostatectomy (RRP). Methods. Of 2293 men treated from 1982 to 1998, 1681 men had a preoperative ACP measurement using an enzymatic assay. We analyzed the actuarial freedom from biochemical (PSA) progression following RRP according to ACP levels. We used multivariate logistic regression and proportional hazards models to determine the independent prognostic value of ACP level with respect of pathologic stage and biochemical recurrence. Results. ACP was not an independent predictor of organ confinement or lymph node involvement in the multivariate logistic regression models using preoperative variables. However, in the proportional hazards model, ACP was an independent predictor of tumor recurrence following RRP, and there was a statistically significant improvement in biochemical recurrence-free survival for men with lower levels of ACP (P

Objectives. To evaluate, using five experienced surgeons, the efficacy of the first-generation Cavermap Surgical Aid to identify the cavernous nerves intraoperatively and to predict the recovery of sexual function. This study was not designed to determine whether this device improves the ability to preserve the nerves or improve outcome. Methods. Fifty men younger than 60 years old (mean age 52.5 years; range 43 to 59) with clinically localized prostate cancer (76% T1c, mean Gleason score 6, prostate-specific antigen level less than 10 ng/mL) underwent nerve-sparing radical prostatectomy (90% bilateral). Intraoperatively, the Cavermap device was used to test for the presence of the cavernous nerves once the neurovascular bundle was identified visually and to determine whether the nerves were intact after the prostate was removed. Erectile function was evaluated using the International Index of Erectile Function; men were considered potent if they were able to achieve unassisted intercourse in at least one half of their attempts. Results. Before the removal of the prostate, the tumescence response to stimulation of the neurovascular bundle was 87.8%; when tissue not containing the neurovascular bundle was stimulated, no tumescence response occurred in 54%. After prostatectomy, a bilateral response to stimulation occurred in 90%, a unilateral response in 5%, and no response in 5%. Postoperatively, 71% of the patients were potent at 12 months. In the patients who demonstrated bilateral stimulation after removal of the prostate, 78% were potent at 12 months. Conclusions. After radical prostatectomy performed by experienced surgeons, patient-reported potency rates in men younger than 60 years of age were high. Cavermap stimulation demonstrated an 87.8% sensitivity and 54% specificity in locating the neurovascular bundle as identified by experienced surgeons. The lack of specificity of this first-generation device limits its application for deciding which structures can be safely preserved or excised. Because virtually all patients demonstrated a positive response after removal of the prostate, the value of stimulation to predict the recovery of sexual function is yet to be determined.

Objectives. To examine the relationship between prostate size and the method of cancer detection in men with organ-confined prostate cancer, and compare prostate size in men with and without cancer. Methods. Prostate volume was evaluated in 720 men who had undergone radical prostatectomy for Stage T1c or Stage T2 cancer. Men with Stage T2 cancer were divided into those treated before 1989 (when widespread prostate-specific antigen [PSA] testing began), or not. Gland volume was also examined in 265 men participating in the Baltimore Longitudinal Study of Aging who had no clinical evidence of cancer. Volumes were compared using linear regression to allow for age. Results. Prostate volume in men with Stage T1c cancer was statistically significantly larger than in men with Stage T2 cancer diagnosed in the pre-PSA era after adjusting for age (P = 0.0001), and statistically significantly larger than in men without cancer above age 47 years based on 95% confidence intervals. Prostate volumes in men with Stage T2 cancer diagnosed in the pre-PSA era and in men without cancer were not statistically significantly different. Conclusions. Prostate volume in men with PSA-detected, organ-confined cancer is larger than in men with palpable organ-confined cancer diagnosed in either the pre-PSA era or PSA era. These discrepancies may reflect a diagnostic bias due to the effect of benign prostatic hyperplasia on serum PSA that results in the selection of men with larger prostates for biopsy.

Objectives. To stratify the prognosis of lymph node-negative, seminal vesicle-positive tumors in men with prostate cancer after radical retropubic prostatectomy. Methods. Sixty cases were analyzed for multiple parameters and correlated with postoperative biochemical (prostate-specific antigen) progression. Variables included Gleason score, primary Gleason pattern, percentage of Gleason pattern 4, any presence of Gleason pattern 5, method of seminal vesicle invasion (SVI), margin positivity, SVI extent, SVI bilaterality, vascular invasion, extent of extraprostatic extension, length of tumor extending along the seminal vesicles, presence of intraductal carcinoma within the prostate, bladder neck margin positivity, and tumor volume. Results. We were able to stratify the prognosis based on the combination of a variation of the Gleason score and margin status and vascular invasion status. Using this stratification, a few patients had an excellent long-term prognosis, with most patients split into two groups, one experiencing rapid and the other slower progression. Conclusions. SVI is not associated with a uniformly poor prognosis. Rather, tumors can be substratified by pathologic parameters into groups with differing prognoses based on routine histologic examination.

Objectives. To determine whether arbitrary minor variances in surgical technique can have a major impact on the recovery of sexual function after radical retropubic prostatectomy. Methods. The surgical procedures of 62 potent men were videotaped prospectively. Eighteen months after the study was initiated, the videotapes were reviewed and specific steps in the surgical procedure correlated with patient-reported potency rates. Results. Four steps were identified that appeared to correlate with the recovery of sexual function: oversewing back-bleeders from the proximal dorsal vein on the anterior surface of the prostate, division of the striated sphincter when placing urethral sutures, division of the posterior striated sphincter, and hemostasis at the end of the case. Conclusions. We believe that retrospective review of intraoperative videotapes has great promise. Because many surgeons use different techniques, it is likely that each individual may be able to identify other important arbitrary variations that may improve their patients’ outcomes. Similarly, for surgeons with less than optimal outcomes, the review of early successful cases may enable them to identify ways that modification of their surgical technique can improve the outcome of future patients. To the best of our knowledge, the use of retrospective review of intraoperative videotapes has not been commonly used in any other surgical field.

Objectives. To assess, in a group of patients who had undergone radical prostatectomy and who were likely to have extraprostatic extension of their tumors based on the previous finding of perineural invasion on needle biopsy, how effective excision of the neurovascular bundle was in reducing the number of positive margins and increasing the potential cure rate. Methods. Eighty radical prostatectomy cases from our institution that had perineural invasion on prostate needle biopsy were retrospectively studied to determine the presence and location of extraprostatic extension, positive margins, and seminal vesicle or lymph node involvement, whether the neurovascular bundle had been excised, and whether tumor was present in the bundle region. Results. In 14 (17.5%) of 80 cases, excising the neurovascular bundle led to a situation in which there was tumor in the neurovascular bundle, all the surgical margins of resection were negative for tumor, and there was no seminal vesicle or lymph node involvement. The remaining cases were equally divided between (a) less aggressive tumors that were organ-confined or had only focal extraprostatic extension with no tumor in the neurovascular bundle and (b) more aggressive tumors that had positive margins or involvement of the seminal vesicles or lymph nodes. Within the latter group, however, there were 9 patients (11.3% of all 80 cases) with negative seminal vesicles and lymph nodes in whom excision of the neurovascular bundle at least reduced the extent of positive margins. Most of the positive margins in patients with tumor in the neurovascular bundle occurred outside the bundle region, and in this study, none of the cases with positive surgical margins were the sole result of failure to excise the neurovascular bundle. Conclusions. When perineural invasion is seen on needle biopsy, the morbidity of resecting one or both neurovascular bundles, which in some cases could turn out to be unnecessary, must be weighed against the benefit of reducing the incidence of positive margins (17.5% of our cases) or decreasing the extent of positive margins (11.3% of our cases).

Objectives To determine the outcome of patients with clinically organ-confined prostate cancer undergoing radical retropubic prostatectomy for cure and incidentally discovered concurrent low-grade non-Hodgkin's lymphoma at time of surgery. Methods From September 1986 to September 1997, 4319 patients underwent radical retropubic prostatectomy at our institution. The records of 10 patients incidentally diagnosed to have low-grade non-Hodgkin's lymphoma at the time of radical prostatectomy were retrospectively reviewed. Results Of 4319 patients requiring radical prostatectomy, 10 (0.2%) were found to have low-grade non-Hodgkin's lymphoma. All 10 men had an uneventful postoperative course. Two patients subsequently developed progression of lymphoma, one of whom required treatment. One patient died of sepsis associated with his lymphoma and 1 patient died of an unrelated malignancy (lung cancer), both 7 years following surgery. Two patients developed biochemical prostate-specific antigen recurrence. The remainder of men were free of prostate cancer recurrence and experienced no progression of lymphoma at an average of 45 months (range 12 to 142). Conclusions Patients with organ-confined prostate cancer, who are candidates for radical prostatectomy, experience long-term prostate cancer-free survival in the face of incidentally diagnosed low-grade lymphoma. Because the management of most incidentally discovered low-grade lymphomas is expectant, patients discovered at surgery to have this clinical entity should not be denied radical prostatectomy.

Objectives . Recent studies suggest the presence of a hereditary form of benign prostatic hyperplasia (H-BPH). This study was undertaken to characterize the histopathologic features of BPH in these men. Methods . Because study subjects with H-BPH were young (mean age 59 years) and had a large prostate (mean prostate weight 61 g), we compared the histopathologic findings in these men with those in two different control groups: (1) age-matched control subjects (mean age 59 years; mean prostate weight 31 g), and (2) prostate weight-matched control subjects (mean age 70 years; mean prostate weight 61 g). Using a color video image analysis system, we morphometrically determined stromal/epithelial ratios in histologic sections taken from 12 men with H-BPH, 36 age-matched control subjects, and 36 prostate weight-matched control subjects. Results . The stromal/epithelial ratio was 2.6±1.4 in the men with H-BPH, 2.7±1.7 in the age-matchedcontrol subjects, and 1.7±0.9 in the prostate weight-matched control subjects. Regression analysis, which controlled for the differences in prostate weight or patient age between men with H-BPH and age-matched and prostate weight-matched control subjects, respectively, revealed a significant difference between men with H-BPH and prostate weight-matched control subjects ( P =0.015) but no difference from age-matched control subjects ( P =0.36). Conclusions . The larger prostates in young men with H-BPH are characterized by a higher stromal/epithelial ratio than are similar-sized prostates in older men with sporadic BPH. This finding gives rise to speculation that H-BPH is associated with an increase in stromal elements.