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The author presents the results of a follow-up study on 918 cases of radical prostatectomy for prostatic cancer performed by 21 urologists. The average follow-up was two years and six months, (from three months to eight years). Mortality caused by the cancer was 1.96% and from all other reasons was 3.05%. 86.82% of the patients have been operated on for clinical stage B 8.49% for stage A. 3.81% for stage C and 0.22% for stage D. Comparison between pre-operative for evaluation and for pathological features show an understaging rate of 52.03%, an overstaging rate of 4.07% and an accurate evaluation in 43.90% of the cases. Almost half on the understaged patients (208 on 422) received adjuvant therapy, but only 14 received adjuvant therapy in the group of 342 patients whose evaluation was accurate. PSA level seems to be an important component in the stadification, since 73.59% patients whose PSA level was under 50 ng/ml did receive an adjuvant therapy, while 21.24% patients whose PSA level was over 50 ng/ml remain without complementary treatment. The post-operative incontinence rate was 11.75%. The post-operative impotence rate was 83.15%.
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PMID:[Results of radical prostatectomies for cancer: a retrospective multicenter study on 918 cases]. 753 Jul 50

It is impossible to adequately answer the question of whether there is a role for CSAP in the management of localized prostate carcinoma without considering the relative advantages and limitations of using other therapies to manage this disease (radical prostatectomy, radiation therapy, hormonal therapy, brachytherapy, expectant observation, and so on). Obviously, this is beyond the scope of this article. It is probably fair to point out, however, that the management of localized prostate carcinoma in the United States is generally quite controversial at the present time, and that despite a considerable amount of data pertaining to these therapeutic alternatives, it is difficult to discern a standard approach that can be broadly applied for all men with this disease. Therefore, if an absence of consensus on the management of localized prostate carcinoma does exist, it seems evident that investigations into alternative therapies are justified, and the preliminary results and efforts investigating CSAP fall well into this paradigm. In this context, several points can be made based on the available information. Significant numbers of patients who undergo CSAP can sustain undetectable levels of PSA for durable periods of time (more than 24 months). Thus, on a clinical level it seems possible to ablate the entire prostate with percutaneous CSAP, although rates of achieving this may be lower than originally anticipated. The reasons for persistence of carcinoma post CSAP are likely technical and related to the difficulties in determining the effective probe placements, number of probes to be used, number of freeze-thaw-freeze cycles to be used, and so on. Previous radiation exposure appears to confer an increased risk of CSAP-related morbidity, with incontinence, tissue sloughing, and rectal injury most prominent. Among nonradiated patients, incontinence is rare, and the most prominent postoperative concern involves BOO/tissue sloughing in a minority of patients. The longest follow-up data available on CSAP suggests that for patients with nonmetastatic prostate carcinoma, CSAP is associated with persistence of carcinoma in only 25% of patients. This compares favorably with the available biopsy data following external beam radiotherapy, in which most reports document positive biopsy results ranging between 30% and 100%, with the majority in the 40% to 50% range. Notably, the positive biopsy rate among patients with stage T3 disease following CSAP at 2 years can be less than 30%, which compares very favorably with previously reported positive biopsy result for these patients following external beam radiation therapy, which ranged between 40% and 100%. The management of patients with persistent carcinoma following CSAP poses fewer concerns to physicians than for those with persistent carcinoma following radiation therapy. Given the number of patients with prostate carcinoma who currently undergo radiotherapy as primary management, these data indicate that CSAP can now be considered a very viable therapeutic alternative for selected patients. With standardizations of technique as well as improved modifications in equipment, these preliminary CSAP results may well improve steadily in the near future. In the absence of randomized, comparative trials, it is difficult to draw meaningful comparisons between CSAP and radical prostatectomy. Based on available information, CSAP appears to be associated with a much lower incidence of stress and total incontinence than is radical prostatectomy. The rates of impotence following CSAP are somewhat comparable to those seen after radical prostatectomy, with wide variation among individual series. For patients who would be ideal candidates for radical prostatectomy (for example, less than stage T2c disease, PSA less than 10 ng/mL, and Gleason score of 7 or less), several authors have noted that the positive biopsy rate between 6 and 12 months is less than 10%.
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PMID:Is there a role for cryoablation of the prostate in the management of localized prostate carcinoma? 877 4

Radical prostatectomy may cure most patients in whom the malignant tumor has not invaded through the prostatic capsule. Advances in surgical technique and accumulation of experience have decreased the complication rate significantly. Long-term results of surgical treatment are now better than those of other forms of treatment; hence radical prostatectomy is now recommended for men with life expectancies longer than 10 years. Between 1988 and 1995, 164 men with clinical stages T1 or T2 adenocarcinoma were admitted for radical prostatectomy. Most were not offered a nerve-sparing procedure, so as to allow wider, more complete resection. Those who wanted preservation of sexual function underwent the nerve- preserving procedure. In 6 patients operation was discontinued when metastases to the mac lymph nodes were detected and in 1 when invasion of the pelvic wall was found, 157 underwent radical prostatectomy. Preoperative biopsy revealed a low-grade lesion (Gleason 2-4) in 19.1%, intermediate grade (Gleason 5-6) in 61.8% and high-grade (Gleason 7-9) in 19.1%; however, pathologic grading revealed that only 7.0% had grade 2-4 tumor, 60.5% grade 5-6 and 32.5% grade 7-9. Pathologic staging revealed T2 tumor in 58%, T3 in 38.8% (including microscopic invasion of the capsule or seminal vesicles); microscopic lymph node metastases were found in 3.2%. Tumor invasion through the capsule was found in only 2 of 13 treated with neoadjuvant androgen blockade, compared with 40% in those who did not receive this treatment. There was no operative mortality and only 14.7% has complications. All had urinary incontinence immediately after operation, but regained continence after an average of 4-5 months, 24 were incontinent for more than 12 months, but most of them had only mild stress incontinence. Most patients were impotent after the procedure. There was tumor recurrence, diagnosed by rise in serum PSA, in 26 during an average followup of 26.4 months (range 3-93). Cure rate of prostatic cancer by radical prostatectomy may be increased by improved preoperative staging methods and better patient selection; long term follow up is required for determining cure rate.
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PMID:[Radical retropubic prostatectomy]. 933 69

A radical prostatectomy for localized prostate cancer is indicated after evaluation of the disease (initial PSA, clinical stage, biopsy mapping, results of radiologic explorations with an endorectal MRI) and the patient (age, morbidity, life expectancy and wishes of potency conservation). The surgical approaches, retropubic or laparoscopic, depend on the surgeon's experience. Radical prostatectomy provides good disease-free survival for organ-confined disease close to the natural life expectancy. Post-radical prostatectomy morbidity is essentially represented by orthostatic incontinence (up to 6.8%), stress incontinence (up to 27%) and impotence (30 to 95%), depending on the published series and patient age.
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PMID:[Methods and results of radical prostatectomy for localized cancer of the prostate]. 1119 47

Sexual function was evaluated in 34 patients with low-risk prostate cancer (PSA < or = 10, Gleason score < or = 6, clinical stage T1/T2) undergoing brachytherapy in a phase III prospective randomized trial comparing iodine-125 ((125)I) to palladium-103 ((103)Pd). The mean and median International Index of Erectile Function (IIEF) scores for the entire group were 14.2 and 16.5, respectively, and there was no difference between these scores when stratified by isotope. IIEF scores < 6, 6 to 11, and > or = 12 were recorded in 35% (12/34), 6% (2/34), and 59% (20/34) of patients, respectively. Hematospermia, orgasmalgia (pain at the time of orgasm), and alteration in intensity of orgasm were documented in 26% (9/34), 15% (5/34), and 38% (13/34) of patients, respectively, but these side effects were of limited duration for most patients. There was no relationship between radiation dose to the neurovascular bundles (NVB), which averaged 209% of the prescribed prostate dose, and the development of postbrachytherapy impotence. All four impotent patients who used sildenafil responded favorably. With a median follow-up of 13 months, 65% of patients undergoing prostate brachytherapy maintained sexual function without pharmacologic support. Including sildenafil responses, 76.5% of patients sustained erections sufficient for sexual intercourse.
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PMID:Short-term sexual function after prostate brachytherapy. 1158 84

Prostate cancer is together with the carcinoma of the lung the most common cancer in the western world. Better screening methods especially the introduction of PSA (prostate specific antigen) in the beginning of the 90's has increased the early detection rate. In the United States only 30% of prostate tumors were in their early stages before the introduction of PSA-screening as compared to 60% nowadays. The early detection also increased the rate of younger men amongst these patients. Patient demands have increased with respect to incontinence and impotence especially amongst those young patients. Radical prostatectomy still is the gold standard for therapy of localized prostate cancer. Better operating techniques have decreased the side effect rate of this operations but many patients still do not undergo this operation because they fear these side effects. Originating from the USA the low dose rate brachytherapy (LDR) using permanent seeds had a renaissance in recent years. In 1999 alone more than 40,000 patients were successfully operated using this technique. 10 year data published in 1998 showed similar results as compared to a multitude of radical prostatectomy studies and superior results to most of the published external beam studies with significantly less side effects. In Germany and western Europe more and more centers start with LDR-brachytherapy. In contrary to the U.S. where brachytherapy is mostly performed as an outpatient procedure, nearly all European centers do only inpatient brachytherapy. Only very few centers perform outpatient procedures; the first results are very encouraging showing few complications and a very high standard of quality of the treatment.
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PMID:[Low dose brachytherapy with seeds--an interdisciplinary therapy alternative to radical prostatectomy]. 1159 8

The important progress achieved in the treatment of prostate cancer comes by exacting significant costs [11, 16-18, 20, 23, 25]. Currently, there is incomplete evidence that the radical interventions at hand significantly reduce the human costs of the disease. Surgery and radiotherapy induce substantial risks of incontinence and impotence. The PSA test has probably decreased the stage at which prostate cancer is diagnosed [15]. Nonetheless, the PSA is a means of earlier detection; it does not elucidate quantitatively distinct modes of treatment. The PSA test is not a means of prostate cancer prevention. The continuing incidence, morbidity, and mortality imposed by this disease strongly indicate that preventive strategies for its control are necessary. Chemoprevention with selenium and other agents offers a promising approach that is undergoing intensive investigation. Randomized trials underway at the authors' center are building on the important clinical trial results reported by Dr. Larry C. Clark. These studies will evaluate the activity of selenium at several points along a continuum ranging from cancerous prostatic tissue in men with diagnosed cancer to premalignant tissue in men with high-grade PIN to healthy tissue in high-risk men with negative biopsy to long-term effects on cancerous tissue in men with frank cancer. These trials will also offer an opportunity for preliminary evaluation of the mechanisms by which selenium treatment could result in the slower development or progression of prostate cancer.
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PMID:Prostate cancer and selenium. 1210 57

Screening of prostate cancer with PSA is a challenge for the aid to decision. Beside the rather mediocre characteristics of the screening test, there the additional problem of the peculiar biology of this cancer, with its late development and its ability to remain latent for a prolonged period. On the other hand, the treatment (surgery, irradiation) is associated with important side-effects: impotence and urinary leakage. Several studies, which appear to be a form of aid to information than aid to shared decision, have been carried out to analyse the effect of various modes of information on the behaviour of potential candidates to screening of prostate cancer, with the following results: better knowledge of the problem, lower rate of acceptance of PSA testing and trend towards watchful waiting rather than surgery in case of discovery of cancer.
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PMID:[Early detection in prostate cancer and shared decision making]. 1622 12

Whereas it has been proposed almost one century ago, brachytherapy for prostate cancer has only recently emerged, especially thanks to endorectal echography, allowing to visualize seed implantation, to the development of seeds for permanent delivery and of micro-sources for high-dose rate delivery, and also to the development of three-dimension dosimetry programs allowing real-time implantations. For selected patients with localized prostate cancer (PSA < 10, Gleason < 7, no extracapsular extension, volume < 50-60 g), prostate brachytherapy with permanent implants (iodine 125 or, less frequently, palladium 103) gives results which appear at 10-15 years comparable to those of surgery. Incontinence and impotence rates appear lower than those of classical surgery. However, the first post-implant months are usually accompanied by urinary toxicity that should not be minimized. High-dose rate brachytherapy (HDR) could find its indications, in combination with conformal radiotherapy, in the treatment of more advanced forms, presenting an intermediate risk. It could also be an alternative to brachytherapy with permanent implants for the low-risk forms mentioned above, especially in developing countries where the cost of radioactive seeds slows down the use of this technique. Brachytherapy for prostate cancer should, therefore, find more and more indications, because of the increased incidence of prostate cancer, due to population ageing, of the increased proportion of localized forms, due to better detection, of the patient's request for less toxicity, and of the expecting lowering of the costs, which are now equivalent to those of surgery and should further lower.
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PMID:[Brachytherapy for prostate cancer: old concept, new techniques]. 1693 80

The risk of death from prostate cancer is very small before age 75: if one follows 1000 men from birth until age 75, one will observe 7 prostate cancer deaths. Prostate cancer is extremely frequent: if one were to autopsy 1000 men aged 75, one would find a cancer in the prostate of 800. Therefore, screening by systematic PSA measurement in the population induces an epidemic. The benefit associated with screening is not clearly established. The assertion that screening reduces prostate cancer mortality by 20% is based on the best result observed in the best subgroup (population aged 55 to 69) in the only trial that shows a benefit. Even if screening reduced prostate cancer mortality by 20%, its drawbacks: a doubling of the number of cancers diagnoses and the unwanted effects of treatments (50% of patients incontinent and/or impotent), weigh against systematic screening. Even if screening reduced prostate cancer mortality by 20%, the absolute benefit of screening in a population of 1000 men aged 55 to 69 followed 9 years will be the avoidance of one prostate cancer death, since the expected number of these deaths without screening is 4, a 20% reduction corresponds to less than 1 death.
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PMID:[Prostate cancer: the evidence weighs against screening]. 2049 43


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