POTENCY, CONTINENCE AND COMPLICATION RATES IN 1,870 CONSECUTIVE RADICAL RETROPUBIC PROSTATECTOMIES

0022-5347/99/1622-043310

THE JOURNAL

Vol. 162,433-438, August 1999 Printed in U S A

OF UROLOGY

Copyright Q 1999 by AMERICAN UROLOGICAL ASSOCIATION, INC.

POTENCY, CONTINENCE AND COMPLICATION RATES IN 1,870 CONSECUTIVE RADICAL RETROPUBIC PROSTATECTOMIES WILLIAM J. CATALONA,* GUSTAVO F. CARVALHAL, DOUGLAS E. MAGER DEBORAH S . SMITH

AND

From the Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri

ABSTRACT

Purpose: We update results in a series of consecutive patients treated with anatomic radical retropubic prostatectomy regarding recovery of erections, urinary continence and postoperative complications. Materials and Methods: One surgeon performed anatomic radical retropubic prostatectomy on 1,870 men, using the nerve sparing modification when feasible. We evaluated recovery of erections and urinary continence in men followed for a minimum of 18 months. Patients who were not reliably potent before surgery, did not undergo a nerve sparing procedure, or received hormonal therapy or postoperative adjuvant radiotherapy were excluded from the analysis of potency rates but not of continence rates. Other postoperative complications were evaluated for the entire patient population. Results: Recovery of erections occurred in 68% of preoperatively potent men treated with bilateral (543 of 798) and 47% treated with unilateral (28 of 60) nerve sparing surgery. Recovery of erections was more likely with bilateral than with unilateral nerve sparing surgery in patients less than 70 years old (71 versus 48%, p <0.001) compared with patients with age 70 years old or older (48 versus 40%,p = 0.6).Recovery of urinary continence occurred in 92%(1,223 of 1,325 men) and was associated with younger age (p <0.0001) but not with tumor stage (p = 0.2) or nerve sparing surgery (p = 0.3). Postoperative complications occurred in 10%of patients overall and were associated with older age (p <0.002) but the incidence declined significantly with increasing experience of the surgeon (p <0.0001). There was no operative mortality. Conclusions: Anatomic radical retropubic prostatectomy with the nerve sparing modification can be performed with favorable results in preserving potency and urinary continence. Better results are achieved in young men with organ confined cancer. Other complications can be reduced with increasing surgeon experience. KEY WORDS:prostatectomy, urinary incontinence, prostatic neoplasms, penile erection, prostate

In 1982 Walsh and Donker introduced a refined technique for performing radical retropubic prostatectomy.’ This operation, called the anatomic or nerve sparing radical prostatectomy, requires the prostate be removed with controlled hemostasis t o allow visualization of the urethral sphincter mechanism and the neurovascular bundles of the corpora cavernosa. With this operation erections and urinary continence can be preserved in the majority of patients, and the reported operative mortality rate is less than 0.5%.2-6 Although the nerve sparing radical prostatectomy has been performed for more than 15 years, there is limited information on postoperative potency and continence rates in large, prospectively followed patient populations. Walsh et a1 reported excellent results, with overall postoperative potency rates of 68% and postoperative continence rates of 92%.3 Favorable results also have been reported from other academic centers.4-6 In contrast, results reported from community series, mixed academic and community series or retrospective patient surveys have been less f a ~ o r a b l e . ~We -~ Previously reported early results of preservation of urinary continence and erectile function in our ~ e r i e s . ’ ~ -We ’ ~ now update our results concerning erectile potency, urinary contlnence rates and other postoperative complications in 1,870 consecutive radical retropubic prostatectomies.

MATERIALS AND METHODS

Patients. One of us (W. J. C.) performed anatomic radical retropubic prostatectomy on 1,870 consecutive men between May 1983 and December 1997 using a modification of the technique originally described by Walsh and Donker. l4 Mean patient age plus or minus standard deviation at the time of surgery was 63 2 7 years (range 38 to 79), and 96% of the patients were white. Most of the patients (1,453, 77%) were potent to varying degrees and came to our center seeking nerve sparing surgery. In these men, including 157 with erections that were not always sufficiently rigid for penetration, we attempted to preserve all or part of 1or both neurovascular bundles, unless there was intraoperative evidence of extension of the cancer beyond the prostate. Of the men categorized as being impotent preoperatively (either did not have erections or did not have reliable erections) many had partial erections that were not always sufficiently firm for penetration. These men came to our center seeking nerve sparing surgery to preserve the erections as much as possible. Overall, 93% of the patients underwent at least a partial nerve sparing procedure to the extent that both neurovascular bundles were not widely resected. Patient clinical characteristics are shown in table 1. Tumor stage. Clinical staging usually consisted of digital rectal examination, determination of serum acid phosphatase levels and radioisotope bone scanning, with confirma*.Requestsfor reprints: Division of Urologic Surgery, Washington nlvers!ty School of Medicine, 4960 Children’s Place, St. Loms, tory imaging studies or bone biopsies when necessary. Many Missom 63110. men also underwent abdominal and pelvic computerized to433

434

COMPLICATIONS AFTER RADICAL PROSTATECTOm TABLE1. Patient characteristics

Mean age I SD (range) 63 2 7 (38-79) No. race (7~): White 1,791 (96) Black 49 (3) Other 30 (1) No. preop. PSA (a):* Less than 2.6 134 (8) 2.6-4.0 135 (8) 982 (57) 4.1-9.9 458 (27) Greater than 9.9 No. clinical stage (9’0): Tla or Tlb 93 (5) 63 1 (34) Tlc 1,109 (59) T2 37 (2) T3 No. pathological stage (70): 1,204 (64) PT1 or pT2 479 (26) PT3a or pT3b 187 (10) FT3c or N1 No. pts. preop. potent ( 7 c ) : t 1,453 (77) No. type surgical procedure (%): Bilat. nerve sparin# 1,610 (86) 134 (7) Unilat. nerve sparing (7) 126 Nonnerve sparing * Preoperative PSA was not available for 161 patients (9%)for whom surgery was performed before PSA testing was routinely used for cancer detection. T Potency defined as presence of erections usually of sufficient rigidity for penetration and preoperative potency status not available for 2 patients. $ Bilateral nerve sparing surgery was performed in 157 patients with partial erections that were not always sufficiently rigid for penetration in whom there was no intraoperative evidence of extraprostatic tumor extension.

mography. We originally used a modification of the JewettWhitmore staging system but to facilitate comparisons with other studies, we retrospectively translated staging into the TNM staging system.15 Pathological staging was performed as previously described.16 Radiution or hormonal therapy. Because of histological evidence of extracapsular tumor extension or positive surgical margins, 80 patients (4%) elected treatment with postoperative adjuvant radiation therapy. These patients were excluded from the analysis of return of erections. After there was evidence of tumor recurrence, that is postoperative prostate specific antigen (PSA) greater than 0.3 ng./ml., 160 patients (9%)received radiation therapy to the pelvis, including 75 (47%) who subsequently also received hormonal therapy. In addition, 57 patients (3%) received early or delayed hormonal therapy for tumor progression. These patients were excluded from the analysis of return of erections if radiation or hormonal therapy was given within 18 months of surgery. Follow up database. Our followup schedule included PSA measurements at 6-month intervals (after January 1987) and digital rectal examination at yearly intervals. Outcomes regarding urinary and sexual function were evaluated either directly by the surgeon during followup or by an annual questionnaire on current urinary and sexual function which was completed by the patient and assessed by a research assistant. If the patient did not respond to the questionnaire within 3 weeks, the research assistant called the patient directly to obtain the information. Although many patients were assessed directly by the surgeon, the questions included on the questionnaire and those asked by the research assistant during the telephone interview were the same as those asked by the surgeon. We considered men potent if they had erections that were sufficiently rigid for penetration and intercourse. We considered men continent if they did not require protection to keep outer garments dry. Patients who leaked a few drops of urine only with severe abdominal straining were also considered continent if they did not require protection. We considered men incontinent if they required any protection to keep clothing dry. The mean followup interval since time of surgery was 50 2 40 months. Excluding men known to be dead, only 5 (0.3% of the total

cohort) were considered lost t o followup (more than 12 months had passed since the last PSA or followup contact). Statistical analysis. To estimate accurately potency rates following radical prostatectomy, we evaluated return of erections only in the subset of patients with at least 18 months of followup for whom erections were reliably sufficiently rigid for penetration preoperatively, who underwent nerve sparing surgery and who did not receive adjuvant radiation or hormonal therapy (see figure). Patients who recovered potency were coded as potent and coding did not change even if they subsequently became impotent. Within this 858 patient subset, we computed chi-square tests to compare the proportion of men for whom erections sufficiently rigid for penetration returned versus those for whom erections did not return by whether the nerve sparing procedure was unilateral versus bilateral, clinical stage (TlaPTlb, Tlc, T2 and T3+) and pathological stage (pTl/pT2,pT3dpT3b and pT3c/N1). We used the Armitage test for linear trends to compare return of erections by age (40 to 49, 50 to 59,60 to 69 and 70 years o r greater), preoperative PSA (less than 2.6,2.6 to 4.0,4.1 t o 9.9 and 10.0 ng./ml. or greater), number of prior radical prostatectomies performed by the surgeon (500 or less, 501 t o 1,000, 1,001 to 1,500 and greater than 1,500) and followup interval (less than 2, 2 to 3.9, 4 t o 5.9 and 6 years or greater).17 We also computed a multivariate logistic model predicting return of erections based on significant parameters from the univariate analysis (those for which p <0.1). We entered continuously scaled parameters (age, number of prior prostatectomies) as simple linear effects and entered categorical factors (clinical stage, pathological stage) as dummy coded predictors. For the dummy coded predictors we defined the lowest stratum as the reference stratum. To test for interactions with age we forced all main effects into the model first, and then used a stepwise selection of all 2-way interactions with age. In the final model we included only interaction terms meeting the significance criterion for entry (score chi square p <0.05).18 We report the Wald statistics and adjusted odds ratios for main effects and significant interactions. We evaluated the return of urinary continence in the subset of 1,325 patients who were followed for a minimum of 18 months (see figure). Patients who recovered continence were coded as continent and coding did not change even if they became incontinent subsequently. Similar to the analysis for return of erections, we used chi-square, Armitage tests and multivariate logistic regression to compare the proportion of patients who were continent versus incontinent, stratified by the aforementioned clinical parameters, with the addition of whether or not the patient had undergone radiation therapy within 18 months of surgery. Finally, we report the proportion of patients with postoperative complications, including vesicourethral anastomotic stricture, thromboembolic complications, inguinal hernia, incisional hernia, wound infection, and cardiovascular, neurological and lymphatic complications. Any complication related to the operation was included up to the last followup evaluation. We used chi-square, Fisher’s exact, Armitage tests and multivariate logistic regression to compare the proportion of men with any complication by clinical parameters (excluding followup interval) as described previously for potency and continence. RESULTS

Return of erections after radical prostatectomy. The men included in the evaluation of potency did not differ from the overall patient series with regard to clinical characteristics (table 2). Return of erections was more likely in men who had bilateral versus unilateral nerve sparing surgery (68% versus 47%, chi-square 11.4, p = 0.001). Combining patients who had either unilateral or bilateral nerve sparing surgery,

COMPLICATIONS AFTER RADICAL PROSTATECTOMY

435

Total of Radical Retropubic Prostatectomy Patients May 1983 -December 1997 (N= 1,870)

At least 18 months of fOllOW-up (N=1,325)

Less than 18 months of follow-up (N=545)

Preoperatively Potent (N=3 18)

(N=1,007)

Radiotherapy or Hormonal therapy Before 18 months of Follow-up (N=103)

No Radiotherapy or Hormonal therapy Before 18 months of FOIIOW-UP (N=858)

Selection of patients studied for continence (1,325)and potency (858) rates

TABLE2. Distribution of patient characteristics for 858 men return of erections was modestly associated with localized included i n analysis of potency pathological stage (68% of men with stage pTl/pT2 tumors Mean age 2 SD (range) 62 2 7 (42-77) had return of erections versus 65% with stage pT3dpT3b No. race (lo): tumors and 53% with stage pT3c/N1 tumors, chi-square 5.4, White 82 1 (96) P = 0.06) but not clinical stage (67%with Tla/Tlb had return Black 20 (2) of erections versus 69% with Tlc, 65% with T2 and 63% with Other 17 12) No. preop. PSA (%):“ T3+, chi-square 1.3, p = 0.7). Return of erections was also 69 (9) Less than 2.6 associated with age. Potency was preserved in 90% of men 56 (8) 2.64.0 treated with either unilateral or bilateral nerve sparing sur429 (57) 4.1-9.9 gery who were in their 40s, 80%in their 50s, 60% in their 60s 193 (26) Greater than 9.9 No. clinical stage (70): and 47% in their 70s (Armitage chi-square 59.9, p <0.0001). 57 (7) T l a or Tlb Additionally, there was a modest linear trend for return of Tlc 260 (30) erections with preoperative PSA (75% for men with preoperT2 533 (62) ative PSA less than 2.6 ng./ml., 73% with 2.6 to 4.0,69% with 8 (1) T3 No. pathological stage (70): 4.1 to 9.9 and 65% with 10.0 ng./ml. or greater, Armitage chi 599 (70) pT1 or pT2 square 2.9, p = 0.08) and followup interval (59% with less 206 (24) pT3a or pT3b than 2 years, 73% with 2 to 3.9, 68% with 4 to 5.9 and 62% 53 (6) pT3c or N1 with greater than 6, Armitage chi-square 3.3, p = 0.07). The No. type surgical procedure (5%): 798 (93) Bilat. nerve sparing Proportion of men with return of erections (combining uni60 (7) Unilat. nerve sparing lateral or bilateral nerve sparing surgery) also increased Patients previously potent with at least 18 months of followup who underWith the number of prior Drostatectomies Derformed bv the nerve sparing without adjuvant radiotherapy at the time of . - procedures . surgeon (61%for less-than500,68%for 506to 1,000 and 70% went analysis. for-1,000 to 1,500, Armitane chi-sauare 4.8. D = 0.03). * Preoperative PSA not available for 111 patients (13%) for whom S u r g e r y was performed before PSA testing was routinely used for cancer detection. ‘be Of nerve sparing Groceduri, pathological stage, age I

.

436

COMPLICATIONS AFTER RADICAL PROSTATECTOMY

and number of prior prostatectomies performed by the surgeon were associated with return of erections (all p cO.1) and, therefore, were included in the multivariate logistic model. Although followup interval was modestly associated with return of erections, we did not include this predictor because of its extensive overlap with number of prior prostatectomies (r = -0.9). Similarly, although preoperative PSA was modestly associated with return of erections, we did not include this parameter in the logistic model because the men with the longest followup interval would necessarily be excluded from the analysis (patients for whom surgery was performed before PSA was routinely used for cancer detection). Entering the 4 main effects first, age X type of surgery was the only interaction term to meet the criterion for inclusion in the model (score chi-square p <0.05). After entering this interaction term, the final model showed a significant 2-way interaction for age X type of surgery (Wald chi-square 6.9, p = 0.009), and nonsignificant effects for pathological stage and number of prior prostatectomies (p >0.1). The significant 2-way interaction for age X type of surgery showed that, controlling for all other predictors, the effect of bilateral versus unilateral nerve sparing surgery on the odds of regaining potency decreased with increasing age (adjusted odds ratios and 95% confidence interval [CI] for return of potency with bilateral versus unilateral surgery at age 40 = 27.9 [3.5 to 222.81, at age 50 = 9.3 [2.6 to 33.41, at age 60 = 3.1 [1.7 to 5.61 and at age 70 = 1.0 [0.5 to 1.91). The rates of return of erections stratified by age are shown in table 3 for patients who underwent bilateral and unilateral nerve sparing surgery, respectively. Return of urinary continence. We evaluated return of continence in 1,325 men followed for more than 18 months (see figure). The distributions of patient characteristics did not differ from the overall patient series (data not shown). Overall, 92% of men (1,223 of 1,325) recovered urinary continence. Two patients underwent placement of an artificial urinary sphincter because of severe stress incontinence. The proportion of those who recovered continence was generally higher in young than in older men (92% of men in their 40s recovered continence, 97% in their 50s, 92% in their 60s and 87% in their 70s, Armitage chi-square 17.4, p
TABLE4. Percentage of 1,325 patients with return of continence after radical retropubic prostatectomy stratified by age No. Postop. ContinencwTotal No. (%) Age 4 w 9 49/53 (92) 50-59 346/358 (97) 6M9 584632 (92) 70 or Greater 244/282 (87) Total 1,223/1,325(92) Patients previously continent with at least 18 months of followup.

curred in 10% of the patients (196 of 1,870). The occurrence of any complication was associated with type of surgery (10% for nerve sparing versus 19% for nonnerve sparing, chisquare 10.2, p = 0.001), clinical stage (18% with Tla/Tlb, 9%, with Tlc, 11% with T2 and 14% with T3, chi-square 8.6, p = 0.041, older age (4% of men in their 40s had complications, 9% in their 50s, 11% in their 60s and 14% in their 70s, Armitage chi-square 9.9, p (0.002) and number of prior prostatectomies performed by the surgeon (18% for less than 500,7% for 500 to 1,000, 11% for 1,001 to 1,500 and 5% for greater than 1,500, Armitage chi-square 28.6, p <0.0001). Complications were independent of pathological stage (chi-square 3.6, p = 0.2) and preoperative PSA (Armitage chi-square 1.1, p = 0.3). Type of nerve sparing procedure, clinical stage, age and number of prior prostatectomies were included in the multivariate logistic model predicting complications (all univariate p <0.1). Entering the 4 main effects first, none of the 2-way interactions with age met the criterion for inclusion in the model. The final model indicated that controlling for all other predictors, age (Wald chi-square 3.9, p = 0.05, adjusted odds ratio 1.2 [95% CI 1.0 to 1.51 per 10-year increase in age) and number of prior prostatectomies performed by the surgeon (Wald chi-square 18.5, p <0.0001, adjusted odds ratio 1.5 [95% CI = 1.2-1.71 per each 500 decrease in prior surgeries performed) remained significant predictors of complications. We also found a trend for type of surgery, with nonnerve sparing surgery associated with a higher risk for complications (Wald chi-square 3.3, p = 0.07, adjusted odds ratio 1.6 [95% CI 1.0 to 2.61). However, clinical stage did not predict complications when adjusting for all other factors (p >0.2). The distribution of specific categories of complications is shown in table 5. Anastomotic stricture was the most common complication, occurring in 4% of the patients. However, the incidence of stricture decreased from 9.6% in the first 500 to 2.4% in the second to 1.4% in the third 500 cases, and to only 1.0% in the last 370 cases (Armitage chi-square 46.7, p <0.0001). Thromboembolic complications were documented in 2% of patients (table 5). They also decreased as the number of prior radical prostatectomies performed increased (3.6% for first, 1.0% for the second and 1.8% for the third 500 cases, and 1.8% for the last 370 cases, Armitage chi-square 2.4, p = 0.1). The remainder of the complications were rare, TABLE5. Percentage of 1,870 patients with postoperative complications excluding impotency and incontinence No. Pts.

TABLE3. Percentage of 858 patients who recowered erections after nerue sparing radical prostatectomy stratified by age and type of surzerv NoRotal No. (%) Age

Bilat. Nerve Sparing

Unilat. Nerve Sparing

Total

40-49 50-59 60-69 70 or Greater Totals

42/46 (91) 220/269 (82) 2291375 (61) 52/108 (48) 543/798 ( 6 8 )

2 (50) 3/9 (33) 20/39 (51) 4/10 (40) 28/60 (47)

43/48 (90) 223/278 (80) 249/414 (60) 56/118 (47) 571/858 (66.5)

% (95%CI)

I1 4 (2.947) Anastomotic stricture 39 2 (1.4-2.7) Thromboembobc Inguinal hernia 25 1 (0.8-1.8) Miscellaneous* 21 1 (0.6-1.6) 15 0.8 (O.Pl.2) Infectious Incisional hernia 11 0.6 ( 0 . 2 4 . 9 ) Lymphatic 7 0.4 (0.1-0.6) Neurological 5 0.3 (0.03-0.5) Myocardial infarction 2 0.1 (0.0-0.2) Total 196 10 (9-11.8) Death 0 0 (nonapplicable) * Includes 6 cases of Peyronie’sdisease, 5 unknown hernia, 1 cholecystitis, 1 catheter related complication, 1 wound hematoma, 1 wound seroma, 1 rectal injury, 1 ureteral injury and 2 unrelated complications. ~

~~

COMPLICATIONS AFTER RADICAL PROSTATECTOMY

437

operative continence and the performance of nerve sparing surgery, tumor characteristics, history of transurethral resection of the prostate, number of prior radical prostatectomies performed by the surgeon or followup interval. Similarly, adjuvant or therapeutic radiotherapy for positive surgical margins or cancer recurrence did not affect continence rates in our series. Other authors have reported simDISCUSSION ilar findings with lower doses of radiation.22 Vesicourethral anastomotic strictures and thromboembolic Our results in preserving sexual and urinary function and our postoperative complications are comparable to those re- events were the most common complications other than imported from other academic prostate cancer treatment cen- potence and incontinence. Complications were less common ters and confirm earlier favorable results in our patient se- in younger patients and in those whose surgery was perries.3-6.13 As expected, younger age was an important formed later in the series. Controlling for these factors there predictor of the return of erections, with 80% or greater of was also a trend for a greater likelihood of complications with men younger than 60 years regaining potency compared with nonnerve sparing surgery. However, the positive effect for the type of procedure performed may be a function of health60 and 47%, respectively, for men in their 60s and 70s. Similar to the results of others,lS the type of nerve sparing ier patients undergoing the nerve sparing procedure. Reducprocedure was also significantly related to the return of erec- tion in the rates of some complications with time can be tions. Fewer than half of the preoperatively potent men who explained at least partly by improvements in surgical techunderwent a unilateral nerve sparing procedure (47%) had nique. For example, since adopting our current technique for recovered erections after 18 months of followup compared to performing the apical dissection, we have refrained from 68 of those who underwent bilateral nerve sparing. This closing the bladder neck too tightly. We previously closed the finding is not surprising as in many patients with intraoper- bladder neck tightly around an 18F catheter, and now we ative evidence of neurovascular bundle involvement on 1 close it to only 22 to 24F but leave an 18F catheter draining side, the surgeon usually extended the dissection more the bladder. Using this approach, our incidence of vesicourethral anastomotic strictures, which was 9.6%in the first 500 widely on the contralateral side as well. Although age and type of nerve sparing procedure were cases, has decreased to little more than 1% in the last important individual predictors, the significant interaction 370 cases. between age and type of surgery indicates that both predicWe have previously reported our routine perioperative pators are necessary to predict most accurately the probability tient care and our policies regarding operative blood loss and of return of erections. For instance, the performance of a blood transfusions.14.23-27 Briefly, we do not clamp the hypobilateral rather than a unilateral nerve sparing procedure gastric arteries during surgery23 and do not routinely use yielded a %fold or greater chance of regaining potency in men minidose heparin to prevent thromboembolic events.24 Most younger than 70 years, but its effectiveness did not differ of our patients preoperatively donate 1or 2 units of blood and from that of the unilateral procedure in men older than 70 receive autologous transfusions during surgery or postoperatively. We usually use the technique of hemodilution alone years (adjusted odds ratio 1.0). Additionally, potency results improved with time in our or in conjunction with autologous blood donations. Our usual series, with better results occurring in more recent patients operative blood loss is about 1,500 ml. and nonautologous compared to the first 500 patients (61 versus 70%), which blood transfusions have been needed in fewer than 9% of may be due to improvements in surgical technique and to patients.zs27 We attribute the low perioperative mortality in more favorable patient selection by virtue of earlier diagnosis our series to careful preoperative, intraoperative and postopthrough PSA screening. The importance of the latter factor is erative evaluation and management. Our results confirm underscored in that the trends for improvement in results that radical retropubic prostatectomy is a safe operation in with time were nonsignificant when controlling for age and appropriately selected patients treated by an experienced pathological stage in the multivariate model. It should also surgical team. A few caveats are noteworthy concerning factors that may be noted that although potency improved with the number of prostatectomies performed, less favorable results were veri- limit the generalization of our results. Potency and contified in men with longer than 18 months but less than 2 years nence rates were assessed by nonobjective methods and in of follow (59%regained potency) compared to those followed many cases data were obtained directly by the surgeon. This for 2 to 4 years (73%). Consequently, more than 18 months procedure is no longer considered the optimal method for are necessary for erections to return in some patients. evaluating surgical outcomes, which would be prospectively Clinicopathological characteristics of the tumor and PSA ascertained by an objective third party not involved in the level were only weakly predictive of postoperative potency. treatment using validated instruments. Such studies are curSimilar to other studies,3 we found a modest trend for worse rently under way at our institution. However, since this is a Potency outcomes with worse pathological stage but this ef- large and prospective series of patients carefully followed for fect was not significant when controlling for age and type of a 15-year interval, we believe that the data are valuable. surgery. Higher preoperative PSA was also modestly associ- Finally, our patient population may not be representative of ated with worse potency outcomes. Patients who had under- the general population of men diagnosed with prostate cangone a prior transurethral resection of the prostate (clinical cer. In conclusion, anatomic radical prostatectomy can stage Tla/"lb) recovered erections with a frequency that was achieve favorable results in terms of preservation of urinary comparable to that of others with organ confined cancer who continence, erectile potency (with at least 18 months of folhad not undergone prior prostatic surgery. lowup), perioperative morbidity and postoperative complicaThe definition of continence used by investigators has var- tions. It is likely that with further refinement of surgical ied widely and reported continence rates may differ because technique, earlier diagnosis of prostate cancer through better of the use of different instruments for evaluation.20,21Defin- methods of early detection, better patient selection and more experience, there will be further improvements in the future. 1% urinary continence as not needing protection to keep the outer garments dry, return of urinary continence occurred in REFERENCES 92% of men overall. 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with delayed inguinal hernia, incisional hernia, cardiovascular complications, wound infection, neurological complications and lymphatic complications occurring in 1%or fewer patients (table 5). There was 1 rectal injury (0.05%) and no perioperative mortality.

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QUESTIONS AND RESPONSES Dr. C. A. Olsson. You reported some variation in the outcome following radical prostatectomy. Is experience of the surgeon a factor? Dr. W. J . Catalona. Yes, I think that surgeon experience is one of the most important factors affecting outcome after radical prostatectomy. Doctor Olsson. Is there a minimum number of surgeries that should be performed for a surgeon to be skilled? Doctor Catalona. It is difficult to make a categorical statement but I think a surgeon has to perform 100 prostatectomies before he/she begins to feel comfortable. I still learn something almost every day, after having performed more than 2,000 prostatectomies. Doctor Olsson. Is there a minimum number before continence becomes a reliable outcome? Doctor Catalona. Again, it is difficult to pick a number but I would say at least 100. The key to preserving continence is doing a good apical dissection without injuring the external sphincter mechanism. This is the most difficult part of the operation to learn. Even with the most experienced surgeons, 1to 2% of patients will have moderately severe incontinence and another 3 to 7% will have appreciable stress incontinence.