640 TESTOSTERONE LEVELS BEFORE RADICAL PROSTATECTOMY FOR PROSTATE CANCER: CLINICAL FEATURE AND TUMOR CHARACTERISTICS IN NORMOGONADAL AND HYPOGONADAL MEN

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The use of a modified clavien system for classification of complications after radical prostatectomy

Quality of life in long-term (5+ years) prostate cancer disease free survivors after radical prostatectomy

Hruza M., Schulze M., Stock C., Teber D., Rassweiler J.

Gacci M.1, Simonato A.2, Varca V.2, Romagnoli A.2, Ambruosi C.2, Venzano F.2, Esposito M.2, Montanaro T.2, Masieri L.1, Lanciotti M.1, Mantella A.1, Rossetti M.A.1, Serni S.1, Carmignani G.2, Carini M.1

Slk-Kliniken, Dept. of Urology, Heilbronn, Germany Introduction & Objectives: Using a modified Clavien classification system for standardized evaluation of perioperative and postoperative complications after laparoscopic radical prostatectomy (LRP) in daily clinical practice in our department. Material & Methods: Complications of 1000 patients during the hospital stay and in the follow-up were recorded prospectively and were classified using the system by Dindo, Demartines and Clavien (Annals of Surgery 2004, 240:205-213). Mean follow-up time was 23.6 months (1-45), mean patient age was 64.0 years (40-84). Results: Complications requiring no special treatment (Clavien grade 1) or requiring noninterventional treatment (Clavien grade 2) were recorded in 5.1% and 11.0% of our patients, the latter including 7.9% who only received blood transfusions for anaemia and 1.8% who had parenteral antibiotics for urinary tract infection. Clavien grade 3 complications occurred in 8.2%, 4.4% could be managed using endoscopic or surgical interventions in local anaesthesia (grade 3a), i.e. cystoscopy-assisted re-catheterisation for urinary retention, stenting of the ureter for prolonged urinary extravasation or percutaneous drainage of lymphocele or urinoma. 3.8% required general anaesthesia (grade 3b), including 2,7% anastomotic strictures treated with holmium laser incision during the follow-up. Potentially life-threatening complications (Clavien grade 4a) with the need for treatment in an intensive care unit was recorded in 14 of 1000 cases, 7 of them had a re-intervention for major bleedings, one for bowel injury with a trocar. The remaining 6 patients suffered from cardiovascular or respiratory complications after surgery. Three patients (0.3%) died within 4 weeks after LRP (Clavien grade 5): Causes of death were myocardial infarction, cardiac arrest and combined respiratory and renal failure after major bleeding and transfusions. Complications were significantly more frequent in patients with larger prostates: Clavien grade 1 and 2 complications were found in 21.8% of patients with prostates > 50 grams versus 14.4% when prostate size was < 51 grams. Grade 3, 4 and 5 complications were recorded in 11.3 % versus 9.1% within the 2 groups mentioned above. In our cohort, cTstage, pT-stage, Gleason score, tumor volume, nerve-sparing, operative time, access (transvs. extraperitoneal), pelvic lymph node dissection and previous transurethral resection of the prostate had no significant influence on complication rates.

1 University of Florence, Dept. of Urology, Florence, Italy, 2University of Genoa, Dept. of Urology, Genoa, Italy

Introduction & Objectives: To assess quality of life (QoL) in prostate cancer (PCa) disease free patients at least 5 years after radical prostatectomy (RP) and the impact of bilateral nerve sparing (BNS) without hormonal treatment (HT) on long term urinary and sexual outcomes. Material & Methods: 367 patients treated with RP for PCa, with PSA≤0.2 ng/mL at the follow up (F.up) ³ 5 years were recruited. By using UCLA-PCI questionnaire, we assessed Urinary Function and Bother (UF, UB), Sexual Function and Bother (SF, SB). All these items were analyzed in univariate and multivariate analysis according to: treatment timing (age at time of RP, F.Up duration, age at time of F.Up), tumor characteristics (preoperative PSA, TNM stage, pathological Gleason score), BNS, and HT. Then, we calculated the differences in SF and SB scores between 93 men with BNS without HT (group A) and 274 men with radical approach or BNS + HT (group B) according to 4 quartile of F.up duration: 5, 6-7, 8-9 and ≥ 10 years. Finally, we assessed the correlation between SF-SB in group A and B according to 4 quartile of F.up. Results: At univariate analysis UF was worse in elderly men at F.up (p=0.02), with adverse tumor characteristics (p<0.01) and under HT (p=0.02). Also UB negatively correlated to adverse pathological features (p<0.00), while men with BNS presented higher UB scores compared with patients treated with radical approach (p=0.02). Only BNS positively correlated with SF (p<0.00) while treatment timing, tumor characteristics and HT resulted negative prognostic factors for SF (p<0.05). Elderly men at F.up, with extended F.up duration and with BNS were less sexually bothered (p<0.00), while men with high stage PCa and HT were more sexually bothered (p<0.00). At multivariate analysis F.up duration had a positive effect on SB (p<0.00), while elderly men at F.up reported poorer UF (p=0.02). High stage negatively affected UB and both SF and SB (p=0.05, p=0.02, p=0.01 respectively); BNS improved UB, SF and SB (p=0.05, P=0.00, p=0.00) while HT worsened UF and SF (p=0.05, p=0.04). Group A presented higher SF compared with group B only at 5 and 6-7 years (p=0.04 and p=0.01), while no differences were reported for SF at 8-9 and ≥ 10 years and for SB at all F.up quartile. The increase of F.up, from the first to the last quartile, in group A is characterized by deterioration of SF and improvement of SB with the consequent leaking of SF-SB correlation at 8-9 and ³10 years (p=0.23 and p=0.65).

Conclusions: The modified Clavien system for complications after LRP can easily be used in daily clinical practice. It is a promising instrument for quality assessment and comparison of complications between different institutions. In our study, we found the size of the prostatic gland to be the only factor influencing the complication rate significantly.

Conclusions: Elderly men at F.up presented a worse urinary continence independently from age at RP or F.up duration. Pathological stage was one of the most important prognostic factor for QoL outcomes. After BNS without HT the SF-SB correlation is maintained up to 7 years after PR: subsequently, all men presented severe erectile dysfunction, but they are minimally sexually bothered.





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Evaluation of cancer control after open and laparoscopic radical prostatectomy Touijer K.T.1, Katz D.1, Secin F.1, Savage C.2, Cronin A.2, Vickers A.2, Reuter V.3, Eastham J.1, Scardino P.1, Guillonneau B.1 Memorial Sloan-Kettering Cancer Center, Dept. of Surgery, Urology Service, New York, United States of America, 2Memorial Sloan-Kettering Cancer Center, Dept. of Biostatistics and Epidemiology, New York, United States of America, 3Memorial Sloan-Kettering Cancer Center, Dept. of Pathology, New York, United States of America 1

Introduction & Objectives: To evaluate the oncological outcome between open retropubic and laparoscopic radical prostatectomy over the last 10 years. Material & Methods: Design, setting and Participants: This is a retrospective analysis of prospectively collected data from 1998 to 2007, 3887 consecutive patients with clinically localized prostate cancer (cT1c-cT3a) underwent radical prostatectomy. 1980 open (ORP) and 1341 laparoscopically (LRP). 566 patients had insufficient information for analysis, were excluded. Measurements: Oncological outcome was measured by surgical margin rate, quality of lymphadenectomy (number of nodes retrieved and nodal metastasis detection rate) and biochemical recurrence (BCR). BCR was defined by PSA ≥ 0.1 ng/ml with a confirmatory rise or the administration of post-operative radiation and/or hormonal therapy. Results: There were no major differences between the ORP and LRP groups in terms of clinical or pathological staging. The overall positive surgical margin rate was 12% for both approaches. The median number of nodes retrieved was 14 and 13 and the rate of nodal metastasis was 7% and 8% for LRP and ORP respectively. The Kaplan Meier recurrence-free probabilities, stratified by patients treated by laparoscopic and open surgery showed very similar probabilities initially, and began to separate at approximately 3 years following surgery. The 5 year recurrence-free probability was 78% (95% CI: 74%, 82%) for laparoscopic and 85% (95% CI: 83%, 87%) for open surgery (risk difference: 7.5%; 95%CI: 3.1, 11.9). Although patients receiving laparoscopic surgery appear to have late recurrences (past 3 years) more frequently, the overall test for a difference in recurrence probabilities by surgical approach did not meet conventional levels of statistical significance (p=0.08). Conclusions: We did not detect a significant difference in the biochemical recurrence rate between open and laparoscopic radical prostatectomies performed over the last 10 years. However, laparoscopic patients did seem to have more recurrences beyond 3 years. Further follow-up is important to establish whether these findings may have been impacted by the surgical learning curve or from cross-institutional differences in post-operative surveillance and management.

Eur Urol Suppl 2009;8(4):280

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Testosterone levels before radical prostatectomy for prostate cancer: Clinical feature and tumor characteristics in normogonadal and hypogonadal men Gacci M.1, Masieri L.1, Lanciotti M.1, Tosi N.1, Mantella A.1, Rossetti M.A.1, Vittori G.1, Giancane S.1, Lapini A.1, Serni S.1, Maggi M.2, Carini M.1 University of Florence, Dept. of Urology, Florence, Italy, Endocrinology, Florence, Italy

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2

University of Florence, Dept. of

Introduction & Objectives: To assess testosterone (T) levels before radical prostatectomy (RP) for clinically localized prostate cancer (PCa), the relation between preoperative T and clinical feature or tumor characteristics, and the overall differences between hypogonadal and normogonadal men with PCa. Material & Methods: 194 men treated with RP for clinically localized PCa were enrolled: age, BMI, preoperative UCLA-PCI questionnaires (UF, UB, SF, SB scores), preoperative T and PSA, pathological stage and Gleason Score were recorded. We calculated the correlations between T and clinical and pathological features with a Pearson correlation coefficient. Moreover, we evaluated the differences in T levels between men with low and high PSA (<10 vs. ³10 ng/mL), stage (pT2 vs. pT3) and Gleason score (5-7 vs. 8-10) with an unpaired samples T-test. Finally, we analyzed the differences in clinical features (age, BMI, UCLA-PCI) and tumor characteristics (PSA, pathological stage and Gleason score) between hypogonadal (T<10 nMol/L) and normogonadal (³10 nMol/L) men, with an unpaired samples T-test. Results: Mean T level was 13.5 (r: 0.5 – 29); 51 (26.3%) men resulted hypogonadal (<10 nMol/L) and 143 (73.7%) normogonadal (³10 nMol/L). T levels were related to BMI (p=0.04) and pathological Gleason score (p=0.05), while were independent from age, UCLA-PCI scores, PSA and pathological stage. Moreover, we reported a significant higher T levels in men with Gleason score 8-10 compared with 5-7 (13.1 vs. 17.2: p=0.000 see figure below), while no differences were reported between high and low PSA (13.5 vs. 13.3, p=0.755) and between high and low pathological stage (13.3 vs. 13.4, p=0.878). Finally, hypo and normogonadal groups were analogous for clinical features (Age: p=0.398; BMI: p=0.127; UF: p=0.548; UB: p=0.078; SF: p=0.745; SB: p=0.446) and tumor characteristics (PSA: p=0.789; stage: p=0.458; Gleason score: p=0.794). Conclusions: At least one fourth of men undergoing to RP are affected by hypogonadism. Patients with poorly differentiated PCa (GS 8-10) presented higher T levels compared with well differentiated neoplasms (GS 5-7). Hypogonadal and normogonadal men affected by PCa presented similar clinical feature and pathologic characteristics.