- Email: [email protected]
Editorial: Prostate Cancer
0022-5347/95/15441453$03.00/0 JOWAI, OF UROLOXY Copyright 0 1995 by AMERICAN UROLOGICAI, ASSOCIATION, INC.
Vol. 154. 1453-1454. October 1995 Printed in U S A
EDITORIAL: PROSTATE CANCER Radical prostatectomy has become the most common major that series patients had a 2 to 3-day hospital stay compared ~Ologicalsurgical procedure in our training program. Scien- to the present series in which patients were treated on an tific evidence is just beginning to accumulate, which shows outpatient basis. All of his patients had previously refused *at a more aggressive attack on prostate cancer results in prostatectomy and the disease was being staged before degreater longevity with less morbidity than the previously finitive radiation therapy. espoused nihilistic approach. However, skepticism abounds With the use of special retractors good exposure can be on the impact this more aggressive surgical approach will obtained through relatively small incisions. Therefore, the have on cause-specific survival in men with prostate cancer. practicing urologist can use an approach and technique (open my opinion it just does not make sense to tell a man that surgery) with which hdshe is comfortable. To date many the prostate biopsy shows “cancer”but that no treatment is more open major urological procedures can be done in an necessary at this time. If we really believe that to be the case outpatient setting if pain is controlled through pre-incisional we should stop referring to a positive biopsy as cancer and infiltration with local anesthesia and nerve blocks at the think of some other term that would not create, for the conclusion of the operation. patient and his family, the terrible anxiety that the word In an attempt to decrease the morbidity of urinary incon*cancer”creates. Although my practice has become narrowly tinence following radical prostatectomy some have advocated focused on pediatric urology and I am seldom involved in the preserving the bladder neck fibers. Wood et al (page 1443) treatment decisions for men with prostate cancer, I continue report on routine biopsies of the preserved bladder neck to to follow with fascination the scientific contributions being determine whether this approach would jeopardize cure. made in prostate cancer by my urological colleagues. The Among 73 consecutive patients from 2 institutions they found previous 4 articles on the prostate in this issue encourage the that 19% had either benign or malignant prostate tissue in use of techniques to decrease staging or surgical morbidity, the biopsies (in 7% and 12% of the cases, respectively).Howlessen surgical complications or extend the indications for ever, in no case was a cancer-positivebladder neck biopsy the using radical prostatectomy in the treatment of prostate only positive marginal biopsy. Of the biopsies positive for cancer. prostate tissue 70% were obtained from the posterior margin Harpster et a1 (page 1435)document their experience with at the bladder neck between the 4 and 8 o’clock positions. rectal injury at the time of radical prostatectomy in 533 Although no one has shown that preserving the bladder neck patients. Of the 8 documented instances of rectal injury is associated with a higher rate of urinary continence, it (1.5%)6 were recognized a t operation and 2 were identified makes sense that preserving the bladder neck sphincter as rectourinary fistulas in the postoperative period. None of mechanism, which alone can provide complete continence, the patients had received preoperative radiation and all had would further decrease the incidence of incontinence after undergone a mechanical (GoLYTELY) and antibiotic bowel radical prostatedomy. For the surgeon who wishes to offer preparation preoperatively. Presumably, all of the patients patients every technique for decreasing the morbidity from were believed to have organ-confined disease but the authors radical prostatectomy, including sparing the bladder neck, it did not include data on clinical or pathological stages. This would seem necessary to submit frozen section biopsies from large experience in radical prostatectomies from a private practice group with such a low incidence of rectal injury the posterior bladder neck before performing the bladder attests to the surgical skills of the private practicing urolo- neck-to-urethra anastomosis. Lerner et al (page 1447)report their experience with radgist in the United States. The take home message that ical prostatectomy for clinically locally advanced prostate Harpster et al attempt to convey is that a preoperative mechanical and antibiotic bowel preparation allows for defini- cancer (stage T3). Of 5,120 patients undergoing radical rettive management of most intraoperatively recognized rectal ropubic prostatedomy and bilateral pelvic lymphadenectomy injuries. Management may include primary repair alone, or 812 had clinical stage T3 disease. They compared the clinical with omental interposition or protective colostomy. Aa they and pathological stages, and found 17% of the cases to be over note in 1,000patients undergoing radical prostatectomy who staged and 33% (N+) to be under staged. Ofthe patients 60% had a preoperative enema only, 9 rectal injuries were treated then received adjuvant therapy, which was a decision left up by primary closure with omental interposition alone (refer- to the individual urologist. Adjuvant therapy was defined as ence 1 in article) and this does not support their conclusions therapy beginning within 3 months after radical prostatecregarding preoperative bowel preparations. In my opinion, a tomy and included external beam radiation alone (7%), hormechanical and antibiotic bowel preparation allows the sur- monal therapy alone (43%) or both regimens (10%). The geon faced with a rectal injury to proceed more confidently results and survival rates were estimated by the Kaplanwith a primary repair and add omental interposition or a Meier method evaluating 5 different criteria: 1)overall surProtective colostomy as necessary based upon the type, size vival (death from any cause), 2)death from prostate cancer (cause-specific survival), 3)survival free of local progression, and location of the rectal injury. A novel approach to outpatient pelvic lymphadenectomyis 4) detection of any clinical progression, either systemic or Presented by Mohler (page 1439).It seems that the enthusi- local without considering prostate specific antigen results, asm of the general urologists for performing laparoscopic and 5) detection of any progression, including prostate spe8Wm-y is diminishing. Mohler outlines a technique for direct cific antigen. They note that in the past, patients considered extraperitoneal access to the obturator-external iliac-hypo- to have clinically advanced local disease (stage C or T3) gastric lymph nodes through 2, 3 cm.lower quadrant inci- treated with monotherapy (surgery, external beam radiation, sions. The number of nodes that he was able to remove com- interstitial seeds or hormones) have had rather poor results. Pared favorably to the number he was able to remove through In the series reporting on monotherapy the patients achieva standard approach. The midline approach through a 6 F. ing local control by a single therapeutic modality have had a incision reported by Steiner and Marshall (reference 6 in longer 10 and 15-year survival free of metastases than those article) seems to me to be more appealing, especially if the who failed to achieve local control. In the present series Patient is a candidate for radical prostatectomy. However, in adding adjuvant therapy resulted in a significant increase in 1453
1454
PROSTATE CANCER
cause-specific survival at 10 and 15 years, and provided excellent control of the local tumor with minimal operative and long-term morbidity. It is difficult to argue with their conclusions. However, they have included only patients with "limited" (but unequivocal) clinical stage T3 prostate cancer. k m e r et al define limited as induration or palpable tumor extending outside the boundaries of the prostate, including into the region of the seminal vesicles but not extending to the pelvic side wall (presumably not fixed) or into the bladder base or trigone as determined at cystourethroscopy. In addition, they include only patients with a low co-morbidity and with a 10-year life expectancy. The decision to implement adjuvant therapy was made by the individual urologist and may have introduced a bias that could affect the results. They state that patients
receiving radiation or androgen ablation therapy 3 m o n t h postoperatively were not considered to have received adjuvant therapy but were included in this study. I do not understand this reasoning. I am personally in support of the more aggressive approach that urologists in the United States are taking in the diagnosis and treatment of prostate cancer. I predict that we will see a decrease in prostate cancer deaths during the next 10 to 15 years and will reverse the trend that seems to be pushing prostate cancer to the number 1cancer killer in men. Kenneth A. Kropp Department of Urology Medical College of Ohio Toledo, Ohio
Vol. 154. 1453-1454. October 1995 Printed in U S A
EDITORIAL: PROSTATE CANCER Radical prostatectomy has become the most common major that series patients had a 2 to 3-day hospital stay compared ~Ologicalsurgical procedure in our training program. Scien- to the present series in which patients were treated on an tific evidence is just beginning to accumulate, which shows outpatient basis. All of his patients had previously refused *at a more aggressive attack on prostate cancer results in prostatectomy and the disease was being staged before degreater longevity with less morbidity than the previously finitive radiation therapy. espoused nihilistic approach. However, skepticism abounds With the use of special retractors good exposure can be on the impact this more aggressive surgical approach will obtained through relatively small incisions. Therefore, the have on cause-specific survival in men with prostate cancer. practicing urologist can use an approach and technique (open my opinion it just does not make sense to tell a man that surgery) with which hdshe is comfortable. To date many the prostate biopsy shows “cancer”but that no treatment is more open major urological procedures can be done in an necessary at this time. If we really believe that to be the case outpatient setting if pain is controlled through pre-incisional we should stop referring to a positive biopsy as cancer and infiltration with local anesthesia and nerve blocks at the think of some other term that would not create, for the conclusion of the operation. patient and his family, the terrible anxiety that the word In an attempt to decrease the morbidity of urinary incon*cancer”creates. Although my practice has become narrowly tinence following radical prostatectomy some have advocated focused on pediatric urology and I am seldom involved in the preserving the bladder neck fibers. Wood et al (page 1443) treatment decisions for men with prostate cancer, I continue report on routine biopsies of the preserved bladder neck to to follow with fascination the scientific contributions being determine whether this approach would jeopardize cure. made in prostate cancer by my urological colleagues. The Among 73 consecutive patients from 2 institutions they found previous 4 articles on the prostate in this issue encourage the that 19% had either benign or malignant prostate tissue in use of techniques to decrease staging or surgical morbidity, the biopsies (in 7% and 12% of the cases, respectively).Howlessen surgical complications or extend the indications for ever, in no case was a cancer-positivebladder neck biopsy the using radical prostatectomy in the treatment of prostate only positive marginal biopsy. Of the biopsies positive for cancer. prostate tissue 70% were obtained from the posterior margin Harpster et a1 (page 1435)document their experience with at the bladder neck between the 4 and 8 o’clock positions. rectal injury at the time of radical prostatectomy in 533 Although no one has shown that preserving the bladder neck patients. Of the 8 documented instances of rectal injury is associated with a higher rate of urinary continence, it (1.5%)6 were recognized a t operation and 2 were identified makes sense that preserving the bladder neck sphincter as rectourinary fistulas in the postoperative period. None of mechanism, which alone can provide complete continence, the patients had received preoperative radiation and all had would further decrease the incidence of incontinence after undergone a mechanical (GoLYTELY) and antibiotic bowel radical prostatedomy. For the surgeon who wishes to offer preparation preoperatively. Presumably, all of the patients patients every technique for decreasing the morbidity from were believed to have organ-confined disease but the authors radical prostatectomy, including sparing the bladder neck, it did not include data on clinical or pathological stages. This would seem necessary to submit frozen section biopsies from large experience in radical prostatectomies from a private practice group with such a low incidence of rectal injury the posterior bladder neck before performing the bladder attests to the surgical skills of the private practicing urolo- neck-to-urethra anastomosis. Lerner et al (page 1447)report their experience with radgist in the United States. The take home message that ical prostatectomy for clinically locally advanced prostate Harpster et al attempt to convey is that a preoperative mechanical and antibiotic bowel preparation allows for defini- cancer (stage T3). Of 5,120 patients undergoing radical rettive management of most intraoperatively recognized rectal ropubic prostatedomy and bilateral pelvic lymphadenectomy injuries. Management may include primary repair alone, or 812 had clinical stage T3 disease. They compared the clinical with omental interposition or protective colostomy. Aa they and pathological stages, and found 17% of the cases to be over note in 1,000patients undergoing radical prostatectomy who staged and 33% (N+) to be under staged. Ofthe patients 60% had a preoperative enema only, 9 rectal injuries were treated then received adjuvant therapy, which was a decision left up by primary closure with omental interposition alone (refer- to the individual urologist. Adjuvant therapy was defined as ence 1 in article) and this does not support their conclusions therapy beginning within 3 months after radical prostatecregarding preoperative bowel preparations. In my opinion, a tomy and included external beam radiation alone (7%), hormechanical and antibiotic bowel preparation allows the sur- monal therapy alone (43%) or both regimens (10%). The geon faced with a rectal injury to proceed more confidently results and survival rates were estimated by the Kaplanwith a primary repair and add omental interposition or a Meier method evaluating 5 different criteria: 1)overall surProtective colostomy as necessary based upon the type, size vival (death from any cause), 2)death from prostate cancer (cause-specific survival), 3)survival free of local progression, and location of the rectal injury. A novel approach to outpatient pelvic lymphadenectomyis 4) detection of any clinical progression, either systemic or Presented by Mohler (page 1439).It seems that the enthusi- local without considering prostate specific antigen results, asm of the general urologists for performing laparoscopic and 5) detection of any progression, including prostate spe8Wm-y is diminishing. Mohler outlines a technique for direct cific antigen. They note that in the past, patients considered extraperitoneal access to the obturator-external iliac-hypo- to have clinically advanced local disease (stage C or T3) gastric lymph nodes through 2, 3 cm.lower quadrant inci- treated with monotherapy (surgery, external beam radiation, sions. The number of nodes that he was able to remove com- interstitial seeds or hormones) have had rather poor results. Pared favorably to the number he was able to remove through In the series reporting on monotherapy the patients achieva standard approach. The midline approach through a 6 F. ing local control by a single therapeutic modality have had a incision reported by Steiner and Marshall (reference 6 in longer 10 and 15-year survival free of metastases than those article) seems to me to be more appealing, especially if the who failed to achieve local control. In the present series Patient is a candidate for radical prostatectomy. However, in adding adjuvant therapy resulted in a significant increase in 1453
1454
PROSTATE CANCER
cause-specific survival at 10 and 15 years, and provided excellent control of the local tumor with minimal operative and long-term morbidity. It is difficult to argue with their conclusions. However, they have included only patients with "limited" (but unequivocal) clinical stage T3 prostate cancer. k m e r et al define limited as induration or palpable tumor extending outside the boundaries of the prostate, including into the region of the seminal vesicles but not extending to the pelvic side wall (presumably not fixed) or into the bladder base or trigone as determined at cystourethroscopy. In addition, they include only patients with a low co-morbidity and with a 10-year life expectancy. The decision to implement adjuvant therapy was made by the individual urologist and may have introduced a bias that could affect the results. They state that patients
receiving radiation or androgen ablation therapy 3 m o n t h postoperatively were not considered to have received adjuvant therapy but were included in this study. I do not understand this reasoning. I am personally in support of the more aggressive approach that urologists in the United States are taking in the diagnosis and treatment of prostate cancer. I predict that we will see a decrease in prostate cancer deaths during the next 10 to 15 years and will reverse the trend that seems to be pushing prostate cancer to the number 1cancer killer in men. Kenneth A. Kropp Department of Urology Medical College of Ohio Toledo, Ohio