OBJECTIVES To investigate the incidence of urinary incontinence and its development over time, to compare the effects of alternative definitions on the incontinence rate and to explore risk factors for incontinence after radical retropubic prostatectomy (RRP) for clinically localized prostate cancer. PATIENTS AND METHODS Urinary continence was assessed using a questionnaire administered by a third party in 1144 consecutive patients after undergoing RRP at our department from January 1986 to December 2001. Overall, 985 men (86%) were suitable for evaluation (mean age 64.5 years, mean follow‐up 95.5 months). We compared the effects of three definitions on the actuarial rate of continence: (1) no or occasional pad use; (2) 0 or 1 pads used daily, but for occasional dribbling only; (3) 0–1 pads daily. The time to recovery of continence was defined as the date on which the patient met the continence definitions. The impact of incontinence on health‐related quality of life (HRQoL) was also evaluated. Univariate and multivariate analyses were used to identify predictors of incontinence, using data gathered prospectively. RESULTS At the last follow‐up at 24 months after RRP, 83%, 92.3% and 93.4% of men achieved continence according to definitions 1, 2 and 3, respectively. The difference in time to recovering continence was significant for definition 1 compared to the others (P < 0.001). Most men using 1 pad/day complained of occasional dribbling only (89.3%), considered themselves continent (98%) and their HRQoL was not as seriously affected as those requiring ≥ 2 pads/day. Men continent (by definition 3) at 2 years had an actuarial probability of preserving continence of 72.2% at the last follow‐up. On multivariate analysis the age at surgery (P = 0.009), anastomotic stricture and follow‐up interval (both P < 0.001) were independent prognostic factors. Bilateral neurovascular bundle resection was another independent predictive factor (P = 0.03) in the subset of the last 560 men with available data on surgical technique. The reduction in the incidence of incontinence over time was as high as 86%. CONCLUSIONS Continence improves progressively until 2 years from RRP but some patients can become incontinent later. The criterion of pad use discriminates well between men with a limited reduction in their QoL (no or one pad used) and those with a markedly affected QoL (≥2 pads/day). It could be clinically valid to consider users of 1 pad/day as continent. Age, bilateral neurovascular bundle resection and anastomotic stricture are significant risk factors for incontinence. There was a marked trend for the incidence of incontinence and anastomotic stricture to decrease with time.
RESULTSWe enrolled 105 patients in the RRP and 103 in the RALP group; the two groups were comparable for all clinical and pathological variables, except median age. For RRP and RALP the respective median operative duration was 135 and 185 min ( P < 0.001), the intraoperative blood loss 500 and 300 mL ( P < 0.001) and postoperative transfusion rates 14% and 1.9% ( P < 0.01). There were complications in 9.7% and 10.4% of the patients ( P = 0.854) after RRP and RALP, respectively; the positive surgical margin rates in pT2 cancers were 12.2% and 11.7% ( P = 0.70). For urinary continence, 41% of patients having RRP and 68.9% of those having RALP were continent at catheter removal ( P < 0.001). The 12-month continence rates were 88% after RRP and 97% after RALP ( P = 0.01), with the mean time to continence being 75 and 25 days ( P < 0.001), respectively. At the 12-month follow-up, 20 of 41 patients having bilateral nerve-sparing RRP (49%) and 52 of 64 having bilateral nerve-sparing RALP (81%) ( P < 0.001) had recovery of erectile function. CONCLUSIONS
during surgery (T1), at the end of anaesthesia (T2), and 12 (T3) and 24 h after surgery (T4), and assayed for interleukin(IL)-6 and IL-1 α , C-reactive protein (CRP), and lactate. The Mann-Whitney U -, Student's t-and Friedman tests were used to compare continuous variables, and the Pearson chi-square and Fisher test for categorical variables, with a two-sided P < 0.05 considered to indicate significance. RESULTSIn all, 35 and 26 patients were assessed for RALP and RRP, respectively; the median (interquartile range) age was 62 (56-68) and 68.5 (59.2-71.2) years, respectively ( P < 0.009). Baseline levels (T0) of IL-1, IL-6, CRP and lactate were comparable in both arms. IL-6, CRP and lactates levels increased during both kinds of surgery. The mean IL-6 and CPR values were higher for RRP at T1 ( P = 0.01 and 0.001), T2 ( P = 0.001 and < 0.001), T3 ( P = 0.002 and < 0.001) and T4 ( P < 0.001 and 0.02), respectively. Lactate was higher for RRP at T2 ( P = 0.001), T3 ( P = 0.001) and T4 ( P = 0.004), although remaining within the normal ranges. IL-1 α did not change at the different sample times. CONCLUSIONSThis study showed for the first time that RALP induces lower tissue trauma than RRP.
Objective: To report our initial experience in the treatment of prostate cancer with robotic-assisted laparoscopic radical prostatectomy (RALP), evaluating our results in terms of learning curve, postoperative outcomes and positive surgical margins. Material and Methods: From April 2005 to February 2006, a single surgeon performed 41 RALP using the da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, Calif., USA). Clinical and pathological data were collected prospectively and analyzed by a researcher from outside our clinic. The main perioperative parameters assessed were the following: operative time, blood loss, transfusion rate, conversion rate, intra- and postoperative complications, hospitalization time, catheterization time, and positive surgical margin rate. To evaluate the learning curve, patients were stratified into three groups: from case 1 to 10 (group 1), from case 11 to 20 (group 2), and from case 21 to 41 (group C). Results: Median operative time was 210 min. Mean blood loss was 400 ml, with 9.8% of the patients receiving blood transfusions. Conversion to open surgery occurred in 2 cases (4.9%), while 4 postoperative complications (9.7%) were reported. Median times of hospitalization and catheterization were 7 days. Positive surgical margins were detected in 26.8% of the cases (6.9% among pT2 patients). Operative time (p < 0.001), blood loss (p = 0.02), transfusion rate (p = 0.006), and postoperative complication rates (p = 0.03) reduced along the learning curve. Conclusion: RALP is a feasible and reproducible technique, with a short learning curve and low perioperative complication rate. Even during the initial phase of the learning curve, good results were obtained with regard to postoperative complications and oncological outcome.
OBJECTIVE To assess the short‐term outcome in patients with high‐risk prostate cancer treated by transrectal high‐intensity focused ultrasound (HIFU). PATIENTS AND METHODS From April 2003 to November 2004, 30 patients with high‐risk prostate cancer were enrolled in this prospective study; all had transurethral resection of the prostate before transrectal HIFU treatment, using the Ablatherm device (EDAP, Lyon, France) during the same session, associated with hormonal therapy with luteinizing hormone‐releasing hormone analogues. After the procedure, all the patients were evaluated every 3 months by physical examination, prostate‐specific antigen (PSA) assay and a continence questionnaire. The follow‐up schedule also included a transperineal prostate biopsy 6 months after the treatment. All the patients had a minimum follow‐up of 12 months. RESULTS The HIFU treatment took a median (interquartile range, IQR) of 140 (100–160) min. No complications were reported during treatment. The mean (IQR) hospitalization was 2.2 (1–4) days, and the suprapubic drainage tube was removed after 12 (7–18) days. The complications after treatment were: urinary tract infections in five patients (16%), stenosis of the intraprostatic and membranous urethra in three (10%), and secondary infravesical obstruction in four (13%). At 12 months after the procedure, 28 patients (93%) were continent. Seven of the 30 men (23%) had a positive prostate biopsy. At the 1‐year follow‐up only three of the 30 patients with high‐risk prostate cancer had a PSA level of >0.3 ng/mL. CONCLUSIONS HIFU is a modern, minimally invasive therapy for prostate cancer, often used in selected patients with localized disease. The present results show that HIFU was also feasible in patients with high‐risk prostate cancer. The low complication rates and favourable functional outcome support the planning of further larger studies in such patients. The oncological efficacy of HIFU should be assessed in further studies with a longer follow‐up.
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