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Salvage Prostatectomy. Correlation Between Pathological Findings and Final Outcome
Accepted 489
490
PAPAVARINE TESTING OF IMPOTENT PATIENTS FOLLOWING NERVE-SPARING RADICAL PROSTATECTOMY. *Robert R. Bahnson, M.D., St. Louis, MO (Presentation to be made by Dr. Bahnson) Recent reports have shown erectile function is preserved in the majority of patients who undergo radical retropubic prostatectomy utilizing a nerve-sparing technique. The return to full erections following surgery requires 3 to 6 months in most patients and some do not have return of full erections for 12 to 15 months. To investigate the etiology of post-surgical erectile dysfunction, we performed papavarine testing on 20 patients who did not have erections sufficient for vaginal penetration following nerve-sparing radical prostatectomy. Intervals from surgery to· testing ranged from 3 to 30 months with an average of 9 months. Sixty mg of papavarine was injected into the corpus cavernosum. A rubber band tourniquet was placed at the base of the penis and left in place for 2 minutes following the injection. The patient was asked to stand and assessment of the erection produced was made by patient estimation of the percentage of preoperative erection and physician observation of the firmness and angle of inclination of the penis. Manual pressure was applied to the glans penis to determine if the penis would buckle with compression. All patients achieved some degree of tumesence. Only l patient (6%) obtained an erection equivalent to his pre-operative state. 0~ 18 patients who were fully potent pre-operatively, 10 (56%) achieved an erection judged sufficient for intercourse (70% or greater erection and firm rigidity); 10 patients (50%) had erections of poor quality insufficient for vaginal penetration (buckling of the penis with glanular pressure). The results suggest that in many of these patients erectile dysfunc:tion following nerve-sparing radical prostatectomy is predommantly vasculogenic in origin. Thus, factors other than injury to the neurovascular bundles may be responsible for post~ur~ical _impotencE:· Fur!her testing and longer follow-up will md1cate if papavarme testmg has predictive value for the return of potency in patients subjected to nerve-sparing radical prostatectomy. ·
SALVAGE PROSTATECI'CMY. CORRELATION BEIWEEN PATHOLOGICAL FINDINGS AND FINAL OUI'COME. J. Edson Pontes, Cleveland, CH (Presentation to be made by Dr. Pontes) An increasing number of patients who have undergone definative radiation therapy, will demonstrate per~istence of tumor in the prostate two years after therapy in the
491
492
SERENOA REPENS IN THE TREATMENT OF lIUlWi BENIGN PROSTA.TIC HYPERTROPHY (BPH), *Ermanno Pannunsio;Roberto D1 asoenso, fsrnando Giardinstti;"Pierluigi Civili and"Emidio Persiohelli,Roma,ltaly (Presentation to be mads by Dr; Pannunzio), Differeutiation,growth and function of the human prostate are dependent upon a oontinuous supply of testioular androgens,mainly teatosterone,Within th• prostate, tsatosterone is reduoed 1,o 5o<.-diicy'drotsatosterons(DHT) by the enzyme 5ot.-reduotase and this 111Stabolite is thought to b• the intracellular mediator of androgen action, In this regard it is of intersat that DHT is elevated 3 to 4 fold in human benign prostatio ~pertropey(BPH) aa compared with normal prostatio tissue, Sereno& Repens ia a lipido-sterolio extraot of the fruit of the dwarf palm tre•, Thia extract inhibita th• enzyme 5.o<,-reduotase, A randomized st~ was caried out on 2 groups of patients with BPH treated with Serenoa Repens and Gestonorone Caproato for 2 montha, Result• based upon olinioal,eohotomographio and urodinamio findinga,showsd a atatistioally significant (p~0.001) improvement of these parameters in the patients treated with Serenoa Rspsne as oompared with the other group, No side effeota war• fouad in ~h• patients treated with Serenoa Repens, These results suggest'tbat Sersnoa Repens represents an interesting oballenge to other hormonal drugs in the medical treatement of BPH.
URODYNAMIC EFFECTS OF PROSTATE SIZE REDUCTION IN BENIGN PROSTATIC HYPERPLASIA (BPH) PATIENTS TREATED BY ANDROGEN DEPRIVATION. Ruud J.L.H. Bosch*, Derek J. Griffiths*, Fritz H. Schroeder, Rotterdam, The Netherlands (Presentation to be made by Dr. Bosch) The symptomatic and urodynamic effects of a reduction in prostate size in BPH patients (pts) treated by androgen deprivation are studied. To Le eligible for the study pts had to show an obstructive pressure-flow relationship together With radiographic narrowing of the proximal urethra at an intake video urodynamic study. Pts were treated for aperiod of 3 months. Of 15 pts being studied, 12 have completed the protocol to date. 6 pts received the anti androgen cyproterone acetate (CPA) 100 mg bid and 6 were treated with the LHRH agonist busereline (BUS) 400 µg tid, intranasally. Pts were seen at 2 to 3 weekly intervals for symptom assessment, determination of flow rate, residual urine and serum testosterone levels and for prostatic sonography. Follow-up urodynamic studies were done after 6 and 12 weeks of treatment and 12 weeks after discOntinuation df treatment. Prostatic size decreased in all except 2 (BUS) pts and plateaued between 6 and 12 weeks. 1 BUS pt never reached castration levels of serum teStosterone. The average volume decrease was 29% (range 15-53%) and 27% (range 0-52%) in CPA and BUS pts respectively. After discontinuation of treatment prostate sizes increased to their initial volumes in 6-28 weeks. Despite the reductions in prostatic volume, no pt showed reversion of an obstructive to an unobstructive pressure-flow relationship. Urethral pressure profiles, peakflow rates and residual urine volumes did not change significantly. A slight decrease of the number of voidings was noted by 2 pts, while hesitancy was reduced in 7 pts. It is concluded that reduction in prostate size in BPH pts treated by androgen deprivation cannot reverse obstructed pts to an unobstructive state; furthermore, the volume reduction is temporary, being maintained only {or a few weeks after stopping treatment.
absence of distant metastasis.
Previously, we repO~ted on
seven patients who µnderwent salvage surgery for this condition. (J. Urol. 133:58,1985). The present study was done to correlate the extent of tumor present in pathological specimens, with the final outcome on those patients. Preoperatively all patients had comPlete clinical staging, and were found to be free of metastasis. All patients had pathological specimen studied by serial sections in order to identify capsular penetration, seminal vesicle involvement and the extent of the tumor. Sixteen patients underwent salvage surgery (12 salvage prostatectomy and 4 salvage cystectomy) between 1980 and 1986, 9 at RPMI and 7 and the Cleveland Clinic Foundation. Clinically one patient was considered A2, two patients B1, five patients B2 and six patients stage c. In two patients accurate staging could not be done due to extensive prior transurethral resections. Pathologically three patients had B2 disease, three c·1 , eight C2 and two D1. All patients had a final histological grade of Gleason's score above 6. Fourteen patients are alivt.ewith follow-up varying from six months to four years and two patients are dead. One of an anesthetic complicia tionlin the immediate p:,stq::erative course, and the other from metastatic disease. Among the fourteen alive patients 10 are NED, while four have deve~oped distant' metastatses. ~11 four patients with metastatic disease, and One that died of metastatic prostatic cancer had semianl ves.ic1e involvement q.nd Gleasol\s scores between 8 and 10. It appears that the majority of patients who failed to radiation therapy and who are still a candidate to salvage surgery have quite extensive local diseases. Despite this, short term results are reasonably good in this selected group of patients.
226A
490
PAPAVARINE TESTING OF IMPOTENT PATIENTS FOLLOWING NERVE-SPARING RADICAL PROSTATECTOMY. *Robert R. Bahnson, M.D., St. Louis, MO (Presentation to be made by Dr. Bahnson) Recent reports have shown erectile function is preserved in the majority of patients who undergo radical retropubic prostatectomy utilizing a nerve-sparing technique. The return to full erections following surgery requires 3 to 6 months in most patients and some do not have return of full erections for 12 to 15 months. To investigate the etiology of post-surgical erectile dysfunction, we performed papavarine testing on 20 patients who did not have erections sufficient for vaginal penetration following nerve-sparing radical prostatectomy. Intervals from surgery to· testing ranged from 3 to 30 months with an average of 9 months. Sixty mg of papavarine was injected into the corpus cavernosum. A rubber band tourniquet was placed at the base of the penis and left in place for 2 minutes following the injection. The patient was asked to stand and assessment of the erection produced was made by patient estimation of the percentage of preoperative erection and physician observation of the firmness and angle of inclination of the penis. Manual pressure was applied to the glans penis to determine if the penis would buckle with compression. All patients achieved some degree of tumesence. Only l patient (6%) obtained an erection equivalent to his pre-operative state. 0~ 18 patients who were fully potent pre-operatively, 10 (56%) achieved an erection judged sufficient for intercourse (70% or greater erection and firm rigidity); 10 patients (50%) had erections of poor quality insufficient for vaginal penetration (buckling of the penis with glanular pressure). The results suggest that in many of these patients erectile dysfunc:tion following nerve-sparing radical prostatectomy is predommantly vasculogenic in origin. Thus, factors other than injury to the neurovascular bundles may be responsible for post~ur~ical _impotencE:· Fur!her testing and longer follow-up will md1cate if papavarme testmg has predictive value for the return of potency in patients subjected to nerve-sparing radical prostatectomy. ·
SALVAGE PROSTATECI'CMY. CORRELATION BEIWEEN PATHOLOGICAL FINDINGS AND FINAL OUI'COME. J. Edson Pontes, Cleveland, CH (Presentation to be made by Dr. Pontes) An increasing number of patients who have undergone definative radiation therapy, will demonstrate per~istence of tumor in the prostate two years after therapy in the
491
492
SERENOA REPENS IN THE TREATMENT OF lIUlWi BENIGN PROSTA.TIC HYPERTROPHY (BPH), *Ermanno Pannunsio;Roberto D1 asoenso, fsrnando Giardinstti;"Pierluigi Civili and"Emidio Persiohelli,Roma,ltaly (Presentation to be mads by Dr; Pannunzio), Differeutiation,growth and function of the human prostate are dependent upon a oontinuous supply of testioular androgens,mainly teatosterone,Within th• prostate, tsatosterone is reduoed 1,o 5o<.-diicy'drotsatosterons(DHT) by the enzyme 5ot.-reduotase and this 111Stabolite is thought to b• the intracellular mediator of androgen action, In this regard it is of intersat that DHT is elevated 3 to 4 fold in human benign prostatio ~pertropey(BPH) aa compared with normal prostatio tissue, Sereno& Repens ia a lipido-sterolio extraot of the fruit of the dwarf palm tre•, Thia extract inhibita th• enzyme 5.o<,-reduotase, A randomized st~ was caried out on 2 groups of patients with BPH treated with Serenoa Repens and Gestonorone Caproato for 2 montha, Result• based upon olinioal,eohotomographio and urodinamio findinga,showsd a atatistioally significant (p~0.001) improvement of these parameters in the patients treated with Serenoa Rspsne as oompared with the other group, No side effeota war• fouad in ~h• patients treated with Serenoa Repens, These results suggest'tbat Sersnoa Repens represents an interesting oballenge to other hormonal drugs in the medical treatement of BPH.
URODYNAMIC EFFECTS OF PROSTATE SIZE REDUCTION IN BENIGN PROSTATIC HYPERPLASIA (BPH) PATIENTS TREATED BY ANDROGEN DEPRIVATION. Ruud J.L.H. Bosch*, Derek J. Griffiths*, Fritz H. Schroeder, Rotterdam, The Netherlands (Presentation to be made by Dr. Bosch) The symptomatic and urodynamic effects of a reduction in prostate size in BPH patients (pts) treated by androgen deprivation are studied. To Le eligible for the study pts had to show an obstructive pressure-flow relationship together With radiographic narrowing of the proximal urethra at an intake video urodynamic study. Pts were treated for aperiod of 3 months. Of 15 pts being studied, 12 have completed the protocol to date. 6 pts received the anti androgen cyproterone acetate (CPA) 100 mg bid and 6 were treated with the LHRH agonist busereline (BUS) 400 µg tid, intranasally. Pts were seen at 2 to 3 weekly intervals for symptom assessment, determination of flow rate, residual urine and serum testosterone levels and for prostatic sonography. Follow-up urodynamic studies were done after 6 and 12 weeks of treatment and 12 weeks after discOntinuation df treatment. Prostatic size decreased in all except 2 (BUS) pts and plateaued between 6 and 12 weeks. 1 BUS pt never reached castration levels of serum teStosterone. The average volume decrease was 29% (range 15-53%) and 27% (range 0-52%) in CPA and BUS pts respectively. After discontinuation of treatment prostate sizes increased to their initial volumes in 6-28 weeks. Despite the reductions in prostatic volume, no pt showed reversion of an obstructive to an unobstructive pressure-flow relationship. Urethral pressure profiles, peakflow rates and residual urine volumes did not change significantly. A slight decrease of the number of voidings was noted by 2 pts, while hesitancy was reduced in 7 pts. It is concluded that reduction in prostate size in BPH pts treated by androgen deprivation cannot reverse obstructed pts to an unobstructive state; furthermore, the volume reduction is temporary, being maintained only {or a few weeks after stopping treatment.
absence of distant metastasis.
Previously, we repO~ted on
seven patients who µnderwent salvage surgery for this condition. (J. Urol. 133:58,1985). The present study was done to correlate the extent of tumor present in pathological specimens, with the final outcome on those patients. Preoperatively all patients had comPlete clinical staging, and were found to be free of metastasis. All patients had pathological specimen studied by serial sections in order to identify capsular penetration, seminal vesicle involvement and the extent of the tumor. Sixteen patients underwent salvage surgery (12 salvage prostatectomy and 4 salvage cystectomy) between 1980 and 1986, 9 at RPMI and 7 and the Cleveland Clinic Foundation. Clinically one patient was considered A2, two patients B1, five patients B2 and six patients stage c. In two patients accurate staging could not be done due to extensive prior transurethral resections. Pathologically three patients had B2 disease, three c·1 , eight C2 and two D1. All patients had a final histological grade of Gleason's score above 6. Fourteen patients are alivt.ewith follow-up varying from six months to four years and two patients are dead. One of an anesthetic complicia tionlin the immediate p:,stq::erative course, and the other from metastatic disease. Among the fourteen alive patients 10 are NED, while four have deve~oped distant' metastatses. ~11 four patients with metastatic disease, and One that died of metastatic prostatic cancer had semianl ves.ic1e involvement q.nd Gleasol\s scores between 8 and 10. It appears that the majority of patients who failed to radiation therapy and who are still a candidate to salvage surgery have quite extensive local diseases. Despite this, short term results are reasonably good in this selected group of patients.
226A