Prostatectomy in private practice; a review of 589 cases in a five-year period

Prostatectomy was done in 589 cases in a five-year period. The operation was done transurethrally in 530 cases of benign disease and in 50 cases of malignant lesions. In six cases of malignant disease and three of benign, open procedures were used. Results of transurethral prostatectomy were considered good or excellent in 94.4 per cent of the cases of benign hypertrophy and in 92 per cent of the cases of carcinoma. It was felt that radical perineal prostatectomy was advisable for early operable cases of carcinoma, but that the transurethral procedure was more suitable in almost all cases of benign hypertrophy.     

PROSTATECTOMY—A Survey of 2,000 Cases

A statistical analysis was made of 2,000 consecutive cases in which prostatic operations were done in the period 1947-1957 at the Southern Pacific General Hospital. The operations included transurethral resections as well as perineal, retropubic and suprapubic prostatectomy.The mortality rates were lowest for transurethral resection and highest for retropubic prostatectomy. Coronary artery disease and pulmonary embolism were the chief causes of death. It was generally felt that preliminary partial vasectomy previous to transurethral resection added very little to successful convalescence. Although distilled water was used routinely for irrigation during transurethral resection, there was no incidence of lower nephron nephrosis.The incidence of recurrence of prostatic obstruction was highest by far after transurethral resection.     

Rabbit model simulating transient hyperglycinemia following transurethral prostatectomy

Summary Glycine was intravenously injected in rabbits and resulted in a dose dependent hyperglycinemia. A dose of 10mmol/kg was sufficient to achieve plasma levels of 10 to 16mM comparable to serum levels in patients at the end of a transurethral prostatectomy. The experiments documented that hyperglycinemia is associated with a significant increase of this substance in tissues outside the plasma compartment. Glycine loading resulted in a tenfold elevation of this amino acid in cerebrospinal fluid 10 minutes after injection. In retina and vitreous humor a five- to tenfold increase in glycine content was observed at 10 minutes post injection while in the anterior chamber fluid the maximum increase appeared at 30 minutes.Significant increases of the glycine content were found in different cerebral structures at 30 minutes post administration.The significant elevations of this neurotransmitter within the central nervous system are prerequisites for possible toxic side effects in the course of transurethral prostatectomy (TURP). Hyperglycinemia might be involved in the pathogenesis of visual disturbances following transurethral prostatectomy and the other neurological complications of TURP syndrome. Our observations add more evidence to this hypothesis.     

Haemodynamic evidence for cardiac stress during transurethral prostatectomy.

OBJECTIVE--To compare haemodynamic performance during transurethral prostatectomy and non-endoscopic control procedures similar in duration and surgical trauma. DESIGN--Controlled comparative study. SETTING--London teaching hospital. PATIENTS--33 men aged 50-85 years in American Society of Anesthesiologists risk groups I and II undergoing transurethral prostatectomy (20), herniorrhaphy (eight), or testicular exploration (five). MAIN OUTCOME MEASURES--Percentage change from baseline in mean arterial pressure, heart rate, Doppler indices of stroke volume and cardiac output, and index of systemic vascular resistance, and change from baseline in core temperature. RESULTS--In the control group mean arterial pressure fell to 11% (95% confidence interval -17% to -5%) below baseline at two minutes into surgery and remained below baseline; there were no other overall changes in haemodynamic variables and the core temperature was stable. During transurethral prostatectomy mean arterial pressure increased by 16% (5% to 27%) at the two minute recording and remained raised throughout. Bradycardia reached -7% (-14% to 1%) by the end of the procedure. Doppler indices of stroke volume fell progressively to 15% (-24% to -6%) below baseline at the end of the procedure, and the index of cardiac output fell to 21% (-32% to -10%) below baseline by the end of the procedure. The index of systemic vascular resistance was increased by 28% (17% to 38%) at two minutes, and by 46.8% (28% to 66%) at the end of the procedure. Core temperature fell by a mean of 0.8 (-1.0 to -0.6) degrees C. Significant differences existed between the two groups in summary measures of mean arterial pressure (p less than 0.05), Doppler indices of stroke volume (p less than 0.005) and cardiac output (p less than 0.005), index of systemic vascular resistance (p less than 0.0005), and core temperature (p less than 0.0001). CONCLUSIONS--Important haemodynamic disturbances were identified during routine apparently uneventful transurethral prostatectomy but not during control procedures. These responses may be related to the rapid central cooling observed during transurethral prostatectomy and require further study.     

Advances in the Management of Post-Radical Prostatectomy Erectile Dysfunction: Treatment Strategies When PDE-5 Inhibitors Don't Work

Phosphodiesterase type-5 (PDE-5) inhibitors have revolutionized the treatment of post-radical prostatectomy erectile dysfunction. For those patients who undergo a non-nerve-sparing radical prostatectomy or whose condition fails to respond to PDE-5 inhibitors, alternative treatment with intracavernous injection therapy, transurethral alprostadil, vacuum erection devices, and recently described combination therapy is available. The goals of therapy are to provide the patient with a means of obtaining an erection so that the patient and his partner may resume sexual relations as soon as possible following radical prostatectomy. There is evidence that early institution of treatment may promote improvement in the return of spontaneous erections in patients who have undergone nerve preservation. In patients who undergo non-nerve-sparing procedures, therapy may improve penile rigidity. Intracavernous injection therapy, transurethral alprostadil, and vacuum devices are highly effective in the management of post-prostatectomy erectile dysfunction. High dropout rates, which are not related to adverse effects, have been described with all 3 modalities. Pre- and postoperative counseling may improve patient and partner satisfaction.     

Prostatectomy in a county hospital; a review of 677 cases in a six-year period

Transurethral procedures were used in 620 of 677 cases in which prostatectomy was done (principally by residents supervised by a urologist) at a county hospital in a six-year period. Open operations were used in the other 57 cases. Results were classified as "excellent" in 46.8 per cent of the transurethral cases and as "good" in 36.3 per cent.     

Laser prostatectomy: checkup on the promises

Voiding symptoms caused by benign prostatic hyperplasia are responsible for significant compromise in the quality of life of many men. As our population ages, more men are seeking medical evaluation and treatment for this condition. In addition, with the recognition that this benign condition rarely creates significant life-threatening medical problems, there has been a movement toward less invasive therapies that are associated with the least possible iatrogenic morbidity. Among the currently available, minimally invasive techniques is laser prostatectomy. Is it standing up to its rival, transurethral resection of the prostate, or lagging behind?     

Costs of minimally invasive laser surgery compared with transurethral electrocautery resection of the prostate.

We reviewed hospital charges for patients undergoing uncomplicated endoscopic surgical resection for symptomatic bladder outlet obstruction due to benign prostatic hyperplasia over a 1-year period at a single institution. Of 115 patients, 67 underwent transurethral electrocautery resection of the prostate, and 48 underwent endoscopic neodymium:yttrium-aluminum-garnet laser ablation of the prostate under direct vision. Analysis showed a cost differential between these 2 surgical treatments in excess of $2,000, favoring laser prostatectomy (P < .0001) over transurethral electrocautery resection. The single greatest difference between the treatments was the ability to manage all patients receiving laser treatment as outpatients, whereas the mean and median hospital stay after transurethral electrocautery resection was 3.0 days. Taking additional cost variables into account and decreasing the cost of laser delivery systems would further increase this cost differential in favor of laser therapy. The diminished postoperative morbidity associated with laser treatment also promises lower total costs over the long term.     

CARCINOMA OF THE PROSTATE—Diagnosis and Treatment

About 28 per cent of men between the ages of 71 and 75 have cancer of the prostate. Many of them do not die of the disease, but with the life span ever increasing, this problem is becoming more important.In the early stages the condition is asymptomatic; when the symptoms of urinary obstruction arise, the cancer is usually too advanced for cure. Cure depends on early diagnosis and, therefore, on routine rectal examination. The solitary hard nodule of early prostatic cancer becomes a stony hard fixed prostate as the condition progresses. X-ray and acid phosphatase studies are of help only after the cancer has metastasized. As many as 50 per cent of patients with rectally palpable early carcinoma of the prostate can be cured by radical perineal prostatectomy. Often, simple enucleation or transurethral resection is sufficient to effect cure in the case of occult carcinoma. However, some observers believe that when cancer is detected by microscopic examination of a prostate that has been removed, a radical operation should be done as soon after the initial operation as feasible. Early orchidectomy and estrogen therapy are of considerable help in slowing the process of advanced prostatic cancer and may postpone the need of transurethral resection to relieve obstruction. When these measures fail, bilateral adrenalectomy, cortisone therapy, pituitary irradiation, and pituitary extirpation have been employed, with moderate success, in an effort to diminish the androgen level.     

Carcinoma of the prostate; diagnosis and treatment

About 28 per cent of men between the ages of 71 and 75 have cancer of the prostate. Many of them do not die of the disease, but with the life span ever increasing, this problem is becoming more important. In the early stages the condition is asymptomatic; when the symptoms of urinary obstruction arise, the cancer is usually too advanced for cure. Cure depends on early diagnosis and, therefore, on routine rectal examination. The solitary hard nodule of early prostatic cancer becomes a stony hard fixed prostate as the condition progresses. X-ray and acid phosphatase studies are of help only after the cancer has metastasized. As many as 50 per cent of patients with rectally palpable early carcinoma of the prostate can be cured by radical perineal prostatectomy. Often, simple enucleation or transurethral resection is sufficient to effect cure in the case of occult carcinoma. However, some observers believe that when cancer is detected by microscopic examination of a prostate that has been removed, a radical operation should be done as soon after the initial operation as feasible. Early orchidectomy and estrogen therapy are of considerable help in slowing the process of advanced prostatic cancer and may postpone the need of transurethral resection to relieve obstruction. When these measures fail, bilateral adrenalectomy, cortisone therapy, pituitary irradiation, and pituitary extirpation have been employed, with moderate success, in an effort to diminish the androgen level.     

Detection of papillomavirus DNA in human prostatic tissue by Southern blot analysis.

Human papillomavirus deoxyribonucleic acid was detected in prostate tissue from patients with benign prostatic hyperplasia or prostatic carcinoma. Radiolabelled genomic probes, specific for the sexually transmitted human papillomavirus types 16 and 18, were used to detect viral genomic sequences in prostate DNA samples analyzed by the Southern blot technique. Viral sequences were identified in DNA from 7 of 16 prostate samples including both hyperplastic and carcinoma tissues and including tissues obtained by transurethral resection or suprapubic prostatectomy. These data indicate that the prostate gland can be infected with human papillomavirus and imply that the prostate may act as a reservoir for the sexual transmission of papillomavirus via seminal fluid. The detection of both episomal and integrated viral DNA sequences in prostate tissue may have important implications for the etiology of prostate disease.     

Open versus laparoscopic radical prostatectomy

Expert laparoscopic surgeons have demonstrated that laparoscopic radical prostatectomy with or without robotic assistance can be performed with excellent results. There is no evidence that laparoscopic radical prostatectomy with or without robotic assistance offers any clinically relevant advantage over open radical prostatectomy. Laparoscopic radical prostatectomy with or without robotic assistance requires a significant learning curve, is a longer surgical procedure, carries greater costs, and requires an expanded operating room team. The literature suggests that laparoscopic radical prostatectomy is associated with more intraoperative complications and higher positive surgical margins. The lesser amount of postoperative bleeding associated with laparoscopic radical prostatectomy is not clinically relevant. Laparoscopic radical prostatectomy is not associated with less pain and does not facilitate earlier urinary catheter removal. The best way to improve overall outcomes after radical prostatectomy is to direct patients to expert open or laparoscopic surgeons.     

A mini-column method for routine measurement of human prostatic androgen receptors

The complex heterogeneous nature of the human prostate gland is such that it is advisable to know the histological characteristics of each sample used for androgen receptor (AR) measurement. Adequate size of sample for AR determination is thus a problem if specimens provided during routine transurethral prostatectomy are to be used for both estimation of AR and histological examination. We present a simple method suitable for these small specimens in which [3H]R 1881 bound to AR is separated from free steroid on mini-columns of controlled-pore glass beads. Data obtained indicate a single class of binding sites of high affinity and low capacity with steroid specificity typical of an androgen receptor. The assay is suitable for samples as small as 20 mg wet weight and is linear using 25-125 microliter cytosol (correlation coefficient 0.995). Intra-assay variation is 6.8% and interassay variation 25.8% (n = 22) over 4 months. A single saturating concentration of steroid measures 97% of AR calculated by Scatchard analysis. Inclusion of high salt (0.4 M KNO3) and 10 mM dithiothreitol in incubation buffer at pH 8.4 are essential; inclusion of 10 mM sodium molybdate in the homogenisation buffer improves measurement. A comparison of AR measured in histologically similar samples obtained by a transurethral resectoscope (TUR) and a cold punch resectoscope (CPR) taken in juxtaposition demonstrated no difference in receptor content. Although carcinomatous samples contained significantly higher receptors levels than benign samples, no differences were observed between TUR and CPR specimens.     

Radical perineal prostatectomy: a more optimal treatment approach than laparoscopic radical prostatectomy in obese patients?

In comparison with laparoscopic radical prostatectomy (LRP), the perineal approach to radical prostatectomy offers specific technical advantages related to obesity and its unique surgical challenges. Radical perineal prostatectomy (RPP) reduces operative time and its associated risk of complication, which may be more pronounced in obese men. It allows for low blood loss, low postoperative use of narcotics for pain, short hospital stays, and requires only 1 small perineal incision. With a proven history of success, RPP presents obese men with an advantageous surgical option.     

Measures of early postoperative mortality: beyond hospital fatality rates.

OBJECTIVE--To quantify the short term risk of postoperative mortality in ways which take account of deaths after discharge and the background risks of death in patients who come to operation. DESIGN--Analysis of linked abstracts of hospital admission records and death certificates for common operations. SETTING--Six health districts in the Oxford region. SUBJECTS--Records of 223,529 operations performed in 1980-6. MAIN OUTCOME MEASURES--In hospital fatality rates, case fatality rates, and standardised mortality ratios at selected time periods during the year after operation and the ratio of early (< 30 days) to late (90-364 days after operation) fatality rates. RESULTS--Fatality rates throughout the year after operations performed after emergency admissions were generally higher than those for similar operations performed after elective admissions and higher than expected from population rates. Examples were prostatectomy, hip arthroplasty, inguinal herniorrhaphy, and cholecystectomy. Common elective operations such as inguinal herniorrhaphy and cataract operations showed no early peak in mortality, but others did. These included transurethral prostatectomy (ratio of early to late mortality 2.0; 95% confidence interval 1.3 to 2.6), hysterectomy (3.2; 1.5 to 6.6), hip arthroplasty (3.8; 2.5 to 5.4), and cholecystectomy (6.9; 4.3 to 11.1). CONCLUSIONS--Temporal profiles of death rates in the year after operation show which operations have early peaks in mortality and which do not. Emergency and elective operations have very different profiles and should be analysed separately. For elective operations for conditions which pose no immediate threat to life the ratio of early to later fatality rates provides a measure of increase in mortality after operation while allowing for the background risk of death in the patient groups.     

Alternative approaches to endoscopic ablation for benign enlargement of the prostate: systematic review of randomised controlled trials

Objective To compare the effectiveness and risk profile of newer methods for endoscopic ablation of the prostate against the current standard of transurethral resection.Design Systematic review and meta-analysis.Data sources Electronic and paper records in subject area up to March 2006.Review methods We searched for randomised controlled trials of endoscopic ablative interventions that included transurethral resection of prostate as one of the treatment arms. Two reviewers independently extracted data and assessed quality. Meta-analyses of prespecified outcomes were done using fixed and random effects models and reported using relative risk or weighted mean difference.Results We identified 45 randomised controlled trials meeting the inclusion criteria and reporting on 3970 participants. The reports were of moderate to poor quality, with small sample sizes. None of the newer technologies resulted in significantly greater improvement in symptoms than transurethral resection at 12 months, although a trend suggested a better outcome with holmium laser enucleation (random effects weighted mean difference −0.82, 95% confidence interval 1.76 to 0.12) and worse outcome with laser vaporisation (1.49, −0.40 to 3.39). Improvements in secondary measures, such as peak urine flow rate, were consistent with change in symptoms. Blood transfusion rates were higher for transurethral resection than for the newer methods (4.8% v 0.7%) and men undergoing laser vaporisation or diathermy vaporisation were more likely to experience urinary retention (6.7% v 2.3% and 3.6% v 1.1%). Hospital stay was up to one day shorter for the newer technologies.Conclusions Although men undergoing more modern methods of removing benign prostatic enlargement have similar outcomes to standard transurethral resection of prostate along with fewer requirements for blood transfusion and shorter hospital stay, the quality of current evidence is poor. The lack of any clearly more effective procedure suggests that transurethral resection should remain the standard approach.     

Systems for Maintenance of Urinary Sterility After Prostatectomy

Closed drainage is recommended for all patients after prostatectomy where hemostasis has been adequate. Although closed drainage can maintain sterility of the bladder, thereby fostering healing and reducing infectious complications, such drainage is not insisted upon at most hospitals because of the inconveniences associated with it. However, when closed drainage was used in 25 consecutive cases of transurethral resection, infection was reduced to 25 per cent (in contrast to the 85 to 100 per cent encountered with open drainage).The ideal closed system should incorporate:1. Fixed tubing to prevent contamination where the catheter joins the tubing and where the tubing is attached to the container;2. An aseptic method of emptying;3. A device to prevent reflux of the potentially contaminated urine in the container into the bladder;4. Free urinary flow from bladder to container; and5. Portability for the patient and convenience for the staff.A system is proposed that incorporates these features. Particularly effective are a fixed drip chamber with vents at the site of attachment of the tubing to the bag and a protected spigot for emptying.     

Management of clinically localized prostate cancer

Critics of screening have stated that early detection of prostate cancer does not necessarily reflect a diminishing death rate from the disease. However, several recent reports have demonstrated that the death rate from prostate cancer is decreasing, representing the most compelling validation for aggressive screening. Prostate cancer can be halted only if there is no evidence of systemic or regional metastases and the disease is confined to the surgical field or the radiation template. Surgeons and radiation oncologists must make a concerted effort to exclude men with regional and systemic metastases who are unlikely to benefit from treatment. With the widespread acceptance of prostate-specific antigen screening, a greater proportion of men are being diagnosed with clinically localized prostate cancer. Both radical prostatectomy and radiation therapy are able to halt disease spread in this significant subset of men, but survival outcomes indicate that radical prostatectomy is a more reliable treatment than radiation therapy for clinically localized prostate cancer. Overall, the immediate treatment-related morbidity of radical prostatectomy and radiation therapy in the modern era is quite low. Radical prostatectomy and radiation therapy appear to have a similar impact on continence and erectile function. There is a need for neoadjuvant and adjuvant therapies that can be utilized in those cases where radical prostatectomy and radiation are less likely to completely eradicate or destroy the cancer.     

经尿道前列腺等离子剜除术对大体积前列腺增生患者尿动力学、性功能及生活质量的影响

摘要 目的：探讨经尿道前列腺等离子剜除术（TUERP）对大体积前列腺增生（BPH）患者尿动力学、性功能及生活质量的影响。方法：回顾性分析我院2016年4月~2019年1月期间收治的118例大体积BPH患者的临床资料,根据手术方式的不同分为经尿道前列腺电切术（TURP）组（n=57,给予TURP治疗）和TUERP组（n=61,给予TUERP治疗）,比较两组患者围术期指标、尿动力学、性功能及生活质量,记录两组患者术后并发症发生情况。结果：TUERP组膀胱冲洗时间、手术时间、尿管留置时间短于TURP组,术中出血量少于TURP组（P<0.05）;TUERP组前列腺膀胱组织切除量多于TURP组（P<0.05）。两组患者术后6个月最大尿流（Qmax）及生理功能、躯体疼痛、社会功能、情感职能、总体健康、生理职能、活力和精神健康等评分升高,且TUERP组高于TURP组（P<0.05）;残余尿量（PVR）降低,且TUERP组低于TURP组（P<0.05）。TUERP组术后并发症发生率低于TURP组（P<0.05）。TUERP组术后6个月勃起功能障碍、逆行射精占比低于TURP组（P<0.05）。结论：TUERP治疗大体积BPH,可有效改善患者围术期指标、尿动力学、性功能及生活质量,同时还可减少并发症发生率,临床应用价值较高。     

High Lysyl Oxidase (LOX) in the Non-Malignant Prostate Epithelium Predicts a Poor Outcome in Prostate Cancer Patient Managed by Watchful Waiting

Lysyl oxidase (LOX) has been shown to both promote and suppress tumor progression, but its role in prostate cancer is largely unknown. LOX immunoreactivity was scored in prostate tumor epithelium, tumor stroma and in the tumor-adjacent non-malignant prostate epithelium and stroma. LOX scores in tumor and non-malignant prostate tissues were then examined for possible associations with clinical characteristics and survival in a historical cohort of men that were diagnosed with prostate cancer at transurethral resection and followed by watchful waiting. Men with a low LOX score in the non-malignant prostate epithelium had significantly longer cancer specific survival than men with a high score. Furthermore, LOX score in non-malignant prostate epithelium remained prognostic in a multivariable analysis including Gleason score. LOX score in prostate tumor epithelium positively correlated to Gleason score and metastases but was not associated with cancer survival. LOX score in tumor and non-malignant prostate stroma appeared unrelated to these tumor characteristics. In radical prostatectomy specimens, LOX immune-staining corresponded to LOX in-situ hybridization and LOX mRNA levels were found to be similar between tumor and adjacent non-malignant areas, but significantly increased in bone metastases samples. LOX levels both in tumors and in the surrounding tumor-bearing organ are apparently related to prostate cancer aggressiveness.