Percutaneous removal of most urinary tract calculi may be performed as a 1-stage effort with techniques and skills developed recently in the specialties of urology and radiology. Ultrasonic fragmentation of most calculi was done to permit their extraction. Percutaneous ultrasonic lithotripsy was performed on 250 consecutive (a single exception) patients bearing stones that required removal. Targeted calculi were removed successfully from 97 per cent of these patients. One patient required surgical lithotomy. The previous 100 patients with stones underwent surgical lithotomy with 96 per cent success. Complications of percutaneous ultrasonic lithotripsy appeared equitable with those of surgical lithotomy. Of the patients who underwent percutaneous ultrasonic lithotripsy 6 (6 per cent) required extended hospital days or additional procedures for management of complications. None of these patients required a surgical incision. Anesthesia times were similar for both groups--average 159 plus or minus 4 (standard error) minutes for percutaneous ultrasonic lithotripsy and 193 plus or minus 8 minutes for surgical lithotomy. Hospital recovery days averaged 5.5 plus or minus 0.3 for percutaneous ultrasonic lithotripsy and 8.4 plus or minus 0.5 for surgical lithotomy (p less than 0.01). Associated costs averaged $7,203 plus or minus 55 for lithotripsy and $8,849 plus or minus 660 for lithotomy (p less than 0.01). The number of narcotic administrations per patient (days 1 to 5 postoperatively) averaged 9.88 plus or minus 0.70 for lithotripsy and 16.82 plus or minus 0.78 for lithotomy (p less than 0.01). The average patient who underwent percutaneous ultrasonic lithotripsy felt capable of full activity 2.0 plus or minus 0.2 weeks following stone removal, whereas no patient who underwent previous surgical lithotomy recalls a recovery period of less than 3 weeks (p less than 0.01). We believe that most upper urinary tract calculi may be removed cost-effectively with a percutaneous approach. Compared to surgical lithotomy, percutaneous ultrasonic lithotripsy may result in rapid convalescence with diminished pain.
Several treatment options currently are available for the patient with clinically localized carcinoma of the prostate and each has its proponents. Comparison of results between institutions becomes necessary to determine the relative value of these treatments, keeping in mind the absence of a suitable control group in any series. Such inter-institutional treatment comparisons are possible only if the patient compositions are similar in terms of age, grade and extent of disease. Comparisons of patients with stage B disease frequently are made because most urologists agree that these patients have palpable disease confined to the prostate and no evidence of metastasis. At our clinic willing patients with clinically localized adenocarcinoma of the prostate who have an expected 15-year survival are treated preferentially with total prostatectomy. We summarize our experience with total prostatectomy in 215 consecutive patients, including 213 who were available for followup. There were 16 patients with clinical stage A, 195 with clinical stage B and 2 with clinical stage C disease. Of these patients 207 underwent radical perineal prostatectomy and there were no operative deaths. Patients did not receive adjuvant hormonal therapy unless disease recurred. Of the 110 patients who have undergone the operation within the last 5 years 98 per cent are alive. Actual survival and survival free of disease, respectively, for the entire series were 55 and 48 per cent at 15 years, 75 and 67 per cent at 10 years, and 94 and 86 per cent at 5 years, compared to 55 and 48, 74 and 67, and 95 and 90 per cent, respectively, for the 195 patients with clinical stage B disease. We believe these results demonstrate that in terms of local control of the disease, over-all survival and survival free of disease total prostatectomy remains the optimal treatment for patients with clinically localized carcinoma of the prostate.
Radical prostatectomy in patients who have had prior transurethral resection of the prostate has been reported to result in significant morbidity. From 1974 to 1982, 30 patients who had had previous transurethral resection of the prostate underwent radical perineal prostatectomy for localized prostatic cancer. Operative time and blood loss were similar to a group of patients who had not had prior transurethral resection of the prostate. Over-all, 3 patients (10 per cent) had total incontinence and 3 (10 per cent) had stress incontinence requiring a pad or device. No patient undergoing radical prostatectomy less than 4 weeks or more than 4 months after transurethral resection of the prostate had postoperative incontinence. When radical perineal prostatectomy was performed between 4 weeks and 4 months after transurethral resection of the prostate the incidence of incontinence was 50 per cent. Five patients experienced prolonged perineal urinary drainage, all but 1 of whom healed spontaneously. Of the 6 patients with incontinence 3 had prolonged drainage. No patient had a rectal injury and there was no operative mortality. Two patients died without cancer and 1 has evidence of disease recurrence. We conclude that radical prostatectomy may be performed safely with acceptable morbidity following transurethral resection of the prostate and that if 4 weeks has elapsed since resection it might be advantageous to wait 4 months before performing radical surgery to lessen the risk of incontinence.
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