299Postoperative pad usage predicts post prostatectomy incontinence

297

298

VESICO-URETHRAL ANASTOMOSIS BIOPSY IN PATIENTS U N D E R G O I N G SALVAGE R A D I A T I O N T H E R A P Y I N C A S E O F P S A FAILURE AFTER RADICAL PROSTATECTOMY: WHEN AND WHY?

TRANS-RECTAL COLOUR DOPPLER CONTRAST ENHANCED (LEVOVIST®) ULTRASOUND IN THE EVALUATION OF URINAL LEAKAGE AFTER RADICAL PROSTATECTOMY: OUR PRELIMINARY REPORT

Rosci~no M), Cozzarini C.2, Seattoni V. t, Da Pozzo L. 1, Sangalli M. t, Colombo R. I, Boceiardi A. 1, Montorsi F. 1, Villa E.2, Rigatti R ~ IVita-Salute University, Urology, Milan, Italy, 2Vita-Salute University, Radiation Therapy, Milan, Italy INTRODUCTION & OBJECTIVES: Radiation therapy (RT) on the prostatic bed is advocated in patients (pts) with locale disease relapse after radical prostatectomy (RRP). The role of the vesieo-urethral anastomosi biopsy before salvage RT (SalvRT) is still controversial. The aim of this study is to analyse anastomotic biopsy usefulness in patients undergoing SalvRT because of a PSA failure after RRP. MATERIAL & METHODS: From January 1992 to June 2001, 86 pts with PSA relapse (defined as serum PSA >0.2 ng/ml after RRP) received a median radiation therapy dose of 70.2 Gy (range: 58.4-73.8 Gy) on the prostatic bed. In 50/86 pts local disease relapse was confirmed by vesico-urethral anastomosis (BxPOS), while in 16 cases prostate bed biopsies were negative (BxNEG); 20 pts underwept. SalvRT without performing biopsy (NoBx). Pathological stage of patients treated was pT2 pN0 in 50 cases and pT3 pN0 in 36 cases. Gleason score (GPS) was <=7 in 63 pts and 8-10 in the remaining. The prognostic impact on the biochemical disease-free survival (bNEDs) of histological confirmation, pre-RT PSA, pathologic stage, GPS, RT dose, adjuvant hormonat treatment, PSA doubling time (PSADT) and time to PSA failure has been evaluated by univariate and multivariate analysis. RESULTS: Median follow-up was 60.1 months (range: 18.2-116.9 months). Univariate analisys showed a 6-year actuarial bNEDs statistically significantly different in BxPOS pts than in the NoBx and BxNEG group (bNEDs 62%vs.27%vs.41%; p-0.05~ log-rank). PSADT and time to PSA failure did not showed any significant correlation with post SalvRT outcome, at multivariate analysis. Multivariate analisys confirmed the independent prognostic impact on bNEDs of the histological confirmation of local relapse (,p - 0.01, HR 2.2), together with the pre-RT PSA value when analysed as a continuous variable (p = 0.01, HR 0.9) and the pathologic stage (pT2 vs. pT3a Vs pT3b; p=0.04; HR 2.1). Instead, while analysing the role of prostatic fossa biopsy on the basis of PSA values, the histological confirmation of local recurrence emerged as an independent prognostic factor of bNEDs after SalvRT only in case ofPSA > 0.8 ng/mL (19=0.04; HR: 1.2). CONCLUSIONS: In cases of PSA failure after RRP, prostatic fossa biopsy may be avoided in case of low pro SalvRT PSA. For higher PSA value (> 0.8 ng/mL), prostate fossa biopsy maintains its prognostic role: a negative histology should require an accurate evaluation of SalvRT treatment or counsel the association of an adjuvant hormonal treatment, due to the possible presence of a micrometastatic disease.

De Stefani S., Sighinolfi M.C., Mofferdin A., Paterlini M., Celia A,, Micali S., Bianchi G. University of Modena, Urology, Modena, Italy INTRODUCTION & OBJECTIVES: Radical prostatectomy represents nowadays the best way of treatment for localized prostate cancer. Early catheter removal (less than 7 days) shortens the recovery time but may increase the risk of fistulas. Any investigation mean is therefore welcome for the detection of urinary leakage. We compared Levovist® enhanced Colour Doppler trans-rectal ultrasound to conventional cystography for the evaluation of vesico-urethral healing after radical pmstatectomy. MATERIAL & METHODS: 30 consecutive patients submitted to radical retropubic prostatectomy for localized prostate cancer (pT2) were prospectively enrolled in the study. A Colnnr Doppler trans-rectal ultrasound (conventional B-mode 7.5 MHz scanning probe) was performed five days after surgery by means of retrograde transcatheter injection of Levovist®, (Schering, Berlin, Germany), an echo-enhancing galactose-based agent containing palmitic acid. A retrograde cystography was also performed in these patients to confirm the ecographyc pattern. All the ultrasound examinations were performed by the same operator. RESULTS: 27 out of 30 patients show a regular vesico-urethral watertight anastomosis whereas a urinal fistula is detected in 3 patients. Retrograde cystography confirms these results. Fistulas were very small in all the cases and were identified only by observing the movement of hyperechoic microbubbles going outside the shape of the anastomotic region. The catheter is removed five days after surgery in all the patients with an anastomotic integrity but in the 3 patients in which a urinary fistula was detected, catheter was left in site 3-4 days more. No adverse event is noticed, neither related to the intravesical administration of Levovist or to the trans-rectal approach of the examination. CONCLUSIONS: Colour Doppler trans-rectal ultrasound with enhancing contrast medium (Levovist®) appears as an effective tool for the evaluation of even minimal vesico-urethral fistulas. The mini-invasiveness, the absence of x-rays exposition and the repetitively of the manoeuvre confirm that this new approach is a valid alternative to traditional cystography. Moreover, in spite of x-rays use, ultrasound can be fully managed by the urologist.

299

300

P O S T O P E R A T I V E PAD U S A G E P R E D I C T S P O S T P R O S T A T E C T O M Y INCONTINENCE

FROZEN SECTION FOR THE MANAGEMENT OF INTRAOPERATIVELY DETECTED PALPABLE TUMOUR LESIONS DURING NERVESPARING SCHEDULED RADICAL PROSTATECTOMY

Wille S., Schrader A., Von K_nobloch R., Hofmann R.

Eiehelber~ C.1, Erbersdobler A. 2, Haese A.t, Graefen M.I, Huland H. 1

Klinikum Lahnberge, Dep. of Urology and Paediatric Urology, Marburg, Germany

~University Hospital Eppendorf, Urology, Hamburg, Germany, 2University Hospital Eppendorf, Pathology, Hamburg, Germany

I N T R O D U C T I O N & O B J E C T I V E S : To evaluate the impact of the number of used pads after catheter removal to predict post prostatectomy incontinence at 3 and 12 months. M A T E R I A L & M E T H O D S : Between January 2000 and May 2003, 403 patients (mean age 66 years, range 36 to 79) with clinical localized prostate cancer underwent radical retropubic prostateetomy. Number of used pads on day 10 after surgery were correlated with continence rates at 3 and 12 months. Continence was defined as usage of no or one pad in 24 hours. Data were available for 396 and 387 patients at 3 and 12 months, respectively. R E S U L T S : O f the patients who used no, one, two to four or five and more pads in 24 hours 100%, 88%, 70% and 34% were continent at 3 months, respectively. O f the patients who used no, one, two to four or five and more pads in 24 hours 100%, 98%, 89% and 55% were continent at 12 months, respectively. Patients who used zero to four pads after catheter removal were then considered as one group and compared to patients who used five and more pads. 92% of the patients who used zero to four pads on day ten after surgery were continent, whereas only 55% of the patients who used five or more pads regained continence at 12. This difference was statistically significant (p<0.001). C O N C L U S I O N S : Our data suggest that patients who use 5 and more pads in 24 hours on day ten after surgery have a poor prognosis to regain continence, whereas patients who use up to 4 pads on day ten after surgery are likely to regain continence at 12 months. Patients who use five or more pads in 24 hours on day 10 after surgery should be offered an anti-incontinence surgery earlier than patients who use up to 4 pads daily.

INTRODUCTION & OBJECTIVES: To identify patients, in whom nerve sparing (NS) radical prostatectomy can oncologically safely be performed, objective preoperative parameters can be combined into nomograms. However, intraoperative findings i.e. palpable mmour lesions are described as a contraindication for NS, although they are of a quite subjective nature. Especially in patients with a strong demand to regain postoperative erectile function, a surgeon might be reluctant to sacrifice neumvascular bundles (NVB) based on this unreliable information. We investigated the use of frozen section (FS) analysis to monitor NS during prostatectomy in patients with intraoperatively identified turnout lesions. MATERIAL & METHODS: In 88 of 613 patients, who received a NS retmpubic RP by a single surgeon, an intraoperative FS was performed. After examination for a palpable tumour close to the capsule, a tangential wedge of 4 cm diameter including the suspicious area was cut off and stained different for capsule and intraprostatic margin. In case of contact of tumour with the capsule, corresponding soft-tissue and the NVB were resected. Otherwise, the NVB remained in situ. In both cases, the prostate specimens were inked with 3 colours to differentiate left and right prostatic capsule and the area corresponding to the frozen section wedge. Surgical margins were declared negative, if no tumour contact was found at the capsule or the outer surface of the secondly resected soft tissue and NVB, in case of a positive FS result. RESULTS: FS prolonged RRP procedure duration for a median of 14 rain, blood loos kept stable with 900ml. Results of FS are listed in Table 1. Patients with palpable tumour knot had pT3 tumours in 34% cases and 61% had Gleason 4 pattern, compared to 18% and 42% for the control group respectively. In 51% of cases we were able to preserve the NVB despite an ipsilateral tumour knot without negatively affecting the margin status. However, Ca was found at the ipsilateral margin in 5.7% of cases, FS had been negative. In contrast, FS set the intraoperative decision to secondly remove the NVB in 41% of FS patients. By doing so, an additional 34% of patients could be declared margin negative, thus reducing positive surgical margin rate especially in pT3-PCa. Table 1 Ca detected in specimen Ca contact with capsule Ca in reseeted NVB/soft tissue

FS analysis (n=88) 92% 41% 14%

CONCLUSIONS: In patients with intraoperatively detected tumour lesions during a NS plarmed RRP, FS objectively supports the decision of secondary NVB resection. On the other hand, we could safely preserve NVB in 51% of cases, despite the finding of an ipsilateral tumour knot. However, surgeon has to be aware of a 5.7% failure rate of the method.

European Urology Supplements 4 (2005) No. 3, pp. 77