Division Of The Dorsal Venous Complex And Urethra

The deep dorsal venous complex that was previously ligated is now divided using the endoshears or the harmonic scalpel. The metal bougie within the prostate helps displace the prostate posteriorly and place the dorsal venous complex on stretch. The curve of the prostatic apex is followed during this procedure to reach the prostatic apex and expose the anterior urethra. During the division of the dorsal venous complex, the previously placed stitch may become dislodged. Bleeding from the complex,...

Info

Witjes WP, Schulman CC, Debruyne FM. Preliminary results of a prospective randomized study comparing radical prostatectomy versus radical prostatectomy associated with neoadjuvant hormonal combination therapy in T2-3 N0 M0 prostatic carcinoma. The European Study Group on Neoadjuvant Treatment of Prostate Cancer. Urology 1997 49(3A Suppl.) 65-9. 28. Lee HH, Warde P, Jewett MA. Neoadjuvant hormonal therapy in carcinoma of the prostate. Br. J. Urol. Int. 1999 83 438-48. 29. Schulman CC,...

Isoflavonoids flavonoids and soy proteins

One of the major differences in diet between Asian and Western countries is the consumption of soy-derived products. Soy bean plant has been cultivated by the Chinese for at least 4500 years and there are more than 2500 known varieties.35 Soy is a well-recognized source of phytoestrogens, also known as isoflavones. A limited amount of clinical evidence points to a beneficial role of soy in reducing hormonal levels and exhibiting weak estrogen and antiestrogen-like qualities. The beneficial...

References

Prostate-specific antigen as a measure of disease outcome in metastatic hormone-refractory prostate cancer. J. Clin. Oncol. 1993 11 607-15. 2. Smith DC, Dunn RL, Strawderman MS etal. Change in serum prostate-specific antigen as a marker of response to cytotoxic therapy for hormone-refractory prostate cancer. J. Clin. Oncol. 1998 16 1835-43. 3. Scher HI, Kelly WK, Zhang ZF etal. Post-therapy serum prostate- specific antigen level and survival in patients with...

RRP after radiotherapy

Salvage RRP after radiotherapy generally encompasses both XRT and brachytherapy in the literature, because of the similar concerns and potential complications with either radiation modality. One of the largest studies, from the Mayo Clinic, reported on 108 patients receiving salvage RRP over 30 years from 1966 to 1996.93 The overall and cancer-specific survival at 10 years was 70 and 43 , respectively. Predictors for cancer-specific survival on multivariate analysis were preopera-tive PSA and...

Vitamin C

Vitamin C is the major circulating water-soluble antioxidant, which acts as a free-radical scavenger, resulting in inhibition of malignant transformation in vitro38 and a decrease in carcinogen-induced chromosome damage.39 Despite the popularity of vitamin C as a cancer preventive, to date no consistent relationship between vitamin C levels and prostate cancer has been demonstrated.40 However, treatment of androgen independent (DU145) and dependent (LNCaP) human prostate cancer cell lines,...

Hifu

Top the same transducer operating at 4.0 MHz is used for imaging and therapy (Sonablate, Focus Surgery Inc., USA). Bottom in this device, two separate transducers for imaging and therapy are incorporated in a transrectal probe sheath (Ablatherm, EDAP-TMS, France). Adapted from Madersbacher etal.4 Fig. 56.1. Transrectal HIFU systems. Top the same transducer operating at 4.0 MHz is used for imaging and therapy (Sonablate, Focus Surgery Inc., USA). Bottom in...

Somatic Changes In Prostate Cancer

While some tumors may contain inherited mutations, all tumors contain acquired or somatic alterations. Advances in the techniques used to examine these changes resulted in the identification of chromosomal regions deleted or amplified that may play a role in tumorigenesis. Chromosomal changes have been identified in specific stages of disease progression with the average number of alterations per case significantly higher in distant metastases than primary tumors.51 As the technology improves,...

Positive Surgical Margins With Extraprostatic Extension Or Seminal Vesicle Involvement

The incidence of extracapsular disease ranges from 28 to 48 .3'13'33 The chance of finding a positive margin is more frequent with tumors of large volume, high Gleason grade and extracapsular penetration. The interaction between extrapros-tatic extension and positive seminal vesicles, Gleason score and positive surgical margin is complex. Tefilli et al. found that Gleason score, positive seminal vesicles and positive margins were significant predictors of PSA failure after radical...

Side Effects Of Selenium And Vitamin E

No discussion of selenium and vitamin E supplements would be complete without mentioning the potential side effects of these popular supplements. The literature reminds us of the potential harm that could exist if someone is selenium deficient. For example, Keshan's disease is a dilated cardio-myopathy that is found in individuals with little to no selenium intake (less than 19 g day) in certain areas of China and other countries.61 However, this disease is a rare finding in most countries, and...

Hereditary Prostate Cancer

In 1895, Dr Alfred Warthin's seamstress told him she was convinced she would die from cancer as so many of her family had. Indeed, she died at a young age from endometrial cancer. This prompted Warthin to publish a description of her family, which included relatives dying prematurely from gastric, endometrial and colorectal cancers. Progress was made in understanding familial cancers in the 1960s by Lynch,9 Li10 and Knudson11 who systematically examined at-risk families. Knudson went on to...

Prostate Evolution Growth And Differentiation

Prostate cancer is the most common non-cutaneous malignancy in American men.10 It is also primarily a disease of men beyond their reproductive years, thereby severely limiting the evolutionary selective process against cancer.11 Observational data suggest that environment plays an important role in determining the risk of prostate cancer. First, there is tremendous species specificity of prostate cancer, with a significant incidence of spontaneous prostate cancer observed only in humans and...

Jack H Mydlo and Matthew Karlovsky

Department of Urology, Temple University School of Medicine, Philadelphia, PA, USA The American Cancer Society has recently stated that one out of five Americans will develop cancer in his or her lifetime. In addition, for those patients who develop a tumor, there is a one out of three chance of developing a second tumor in their lifetime. This suggests that there may be an underlying problem with the person's immune surveillance system, or something inherently wrong with their genetic...

Operative technique

We have used the technique reported by Onik et al. and Pisters etal. The CRYOCare system (Endocare Inc, Irvine, CA) was utilized, and made use of argon and helium gases to freeze and thaw the tissue, respectively. Cryosurgical procedures were performed under spinal anesthesia. Briefly, under flexible cystoscopic guidance, a 10F Cook suprapubic catheter is placed and the bladder was left distended. A urethral warming catheter was then inserted prior to freezing the tissue (CMSI, Maryland). It...

Potential Advantages And Disadvantages Of Anns

There are advantages as well as disadvantages to the use of ANNs in predictive modeling. A powerful advantage of ANNs over other techniques is the ability of ANNs to automatically resolve non-linear complex relationships between variables without the need for prior assumptions about the nature of these relationships. ANNs have demonstrated the ability to approximate arbitrarily complex functions or systems, regardless of the presence of multiple variables or the complexity of their...

Race And Ethnicity

Prostate cancer in the USA is the most often diagnosed non-cutaneous cancer of males and the second leading cause of cancer death.3 The number of prostate cancer cases varies widely among different racial and ethnic groups. It has been well established that African Americans have a greater incidence of prostate cancer than any other racial or ethnic group. Furthermore, the mortality is much greater in this group. The Surveillance, Epidemiology, and End Results (SEER) Program of the National...

Complex Psa Following Radical Prostatectomy

PSA has become the most valuable tool for detecting, staging and monitoring prostate cancer in the past decade.31 After suggesting that the half-life of PSA might be a possible factor for the prognosis after radical prostatectomy, the pharmaco-kinetics of PSA gained more attention.32,33 PSA half-life is 2-3 days34 and a biphasic model for t fPSA elimination was established.34 Lein etal. confirmed the biphasic elimination and suggested the first phase of free PSA loss might be the result of its...

Vascular Supply

The principal arterial supply to the prostate is provided by branches of the inferior vesical artery, which is in turn supplied by the hypogastric artery. The capsular artery and its branches run posteriolateral to the prostate in parallel with the cavernosal nerves. The branches of the capsular artery enter the prostate at a right angle and can be sources of bleeding during dissection, while the artery itself terminates in the pelvic diaphragm. Occasionally an aberrant pudendal artery can be...

Seminal Vesicle Dissection

After the ports are placed, the patient is placed in a 40 steep Trendelenburg position. It is ensured that the bladder is empty by using the suction irrigator to evacuate the urine within the Foley catheter, since the Foley catheter does not adequately drain the bladder in a steep Trendelenburg position. The sigmoid colon is retracted superiorly by the assistant using the right lateral port. The suction irrigation is used through the lower midline port by the assistant to help with suction...

Impact Of Margin Location And Extent Of Margin Involvement

The impact of margin location on tumor progression and disease-free survival is unclear. The site and degree of margin involvement may have important implications regarding the risk of residual cancer and prognosis. Watson etal. reported that patients with tumor involvement at more than one margin site (in general reflecting larger tumor volume) had a 48 progression rate compared to a 29 progression rate for those with a single positive margin.9 They reported a 0 progression in men with a...

Fascial Anatomy

The retropubic approach to the prostate consists of the initial identification and incision of several facial layers starting with the midline incision of the endopelvic fascia to avoid the exposure of the underside of the rectus muscles and damage to the epigastric vessesls (Fig. 28.1). Exposure of the pelvis reveals the parietal fascia of the pelvis, which condenses at the sulci on either side of the bladder to form the tendinous arch of the pelvis.6'7 The component of this fascia that sweeps...

Vitamin E Supplements Dietary Sources And Smokers

Vitamin E did not receive much attention as an anti-prostate cancer agent until the results of the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study (ATBC Study) were released in 1998.32 Over 29 000 male smokers were involved in this 5-8-year study that was designed primarily to determine if either vitamin E and or P-carotene supplements could prevent lung cancer. Again, as in the selenium supplement trial, prostate cancer was not the primary end-point. There was a 32 reduction in the...

Sun Exposure And Prostate Cancer

Exposure to sunlight can have significant effects on human endocrinology. In particular, vitamin D is synthesized via exposure of the skin to ultraviolet light, which in turn, becomes subsequently hydroxylated in the liver and kidney to its active form, 1,25-dihydroxy vitamin D. In 1990, Schwartz and Hulka published their hypothesis about vitamin D and prostate cancer.77 They rationalized that many of the known risk factors for prostate cancer could potentially be explained by vitamin D...

Brachytherapy after XRT

Salvage brachytherapy after XRT failure has been reported in two small studies98'99 but remains controversial. The biologic effect of additional radiation on a presumably radioresistant tumor remains unknown. The reported 5-year PSA recurrence-free rates were 34 and 53 , respectively. A postimplant PSA nadir < 0.5 was predictive of PSA recurrence-free survival.98 The reported complications were not insignificant, however, with a 24 incontinence rate in one series,99 and a TURP rate of 14 and...

Radical Prostatectomy Versus External Beam Radiation

Although early reports comparing the two modalities demonstrated a clear advantage for RP over external beam radiation therapy (EBRT),16'17 the studies were shown to have several flaws. More recent retrospective studies have evaluated the treatment outcomes of EBRT and RP in comparably staged prostate cancer patients. When stratified by preoperative biopsy grade, T stage and serum PSA, the rates of biochemical relapse-free survival and cause-specific survival for the two modalities were similar...

Bladder Neck Dissection

Bladder neck dissection is now performed by the authors using the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH), although the endoshears with bipolar coagulation may also be used. The plane of dissection between the base of the prostate and the bladder neck is identified by the margin of the perivesical fatty tissue (Fig. 37.7). Also the distinction of the floppy bladder wall and the solid prostatic surface can be visualized by gently tapping on the anterior surface of the bladder...

Anastomosis

As we position the patient in the low lithotomy position, a sponge stick is placed to the perineum and cephalad pressure is applied by the assistant to expose the urethral stump. If the patient is supine, the Greenwald sound with retractor blades may be necessary to expose the stump. Six 2-0 Mono-cryl sutures on UR-6 needles are inserted, avoiding the 5 and 7 o'clock positions in nerve-sparing cases. One or both of the anterior sutures incorporate the dorsal venous complex for additional...

Cyproterone Acetate

Since the late 1970s the steroidal androgen receptor antagonist and antiprogestational agent, cyproterone acetate (CPA), has been available. Jacobi et al. and later Tunn showed cyproterone acetate in a dose of 300 mg weekly by intramuscular injection is as effective as diethylstilbestrol in a dose of 3mg day.n'12 In 1976, the European Organization for Research and Treatment in Cancer (EORTC) started a randomized phase III study of cyproterone acetate, 250mg day versus diethyl-stilbestrol (DES)...

Cavermap Surgical Aideassisted Confirmation Of The Cavernosal Nerves

Paraesophageal Hernia Mesh

The CaverMap Surgical Aide device consists of a probe that delivers a biphasic electrical current pulse via a small metal tip and a mercury-filled tumescence sensor that measures changes in penile girth. During nerve stimulation, the device delivers increasing amounts of the biphasic current via the probe tip (from 8 to 20 mA, current increases every 20 seconds). Changes in penile girth, as measured by the mercury-filled tumescence sensor, are reported as a percentage change in the device's...

Selenium Supplements And Dietary Sources

Lower serum levels of the mineral selenium have been linked to numerous cancers over the past few decades.2 In fact, it was this and other findings that were the impetus for the Nutritional Prevention of Cancer Study.3,4 This was a double-blind trial of dietary selenium supplementation whose primary goal was to establish whether or not selenium supplements have any role in reducing the recurrence of skin cancer in individuals at high risk for this disease. The primary end-points for this trial...

Preoperative Counseling

New patients seen in the clinic need individual face-to-face time for counseling, preferably in conjunction with their spouse or significant other. A complete history and physical, medical and family history, etc. is completed with special attention to comorbid factors, prior cancers, smoking habits, etc. that may affect their longevity. A life expectancy of 10 or more years for a surgical candidate is an accepted figure. Patients over age 70 are occasionally considered for surgery, if highly...

Pathways Preventing Apoptosis

The inhibitors of apoptosis proteins (IAPs) are a recently identified group of antiapoptotic proteins. So far, five members have been identified in human cells NAIP, cIAP-1, cIAP-2, XIAP and survivin. The first human IAP discovered was NAIP,9 which was absent in most cases of severe spinal muscle atrophy, a rare autosomal recessive disorder of infancy, characterized by progressive apoptosis of spinal muscle motor neurons.10'11 Subsequent work confirmed that NAIP was cytoprotective and...

Bladder Neck Reconstruction

Bladder neck reconstruction is normally not required, since the bladder neck is preserved during bladder neck dissection. The diameter of the lumen of the bladder neck usually corresponds to the lumen of the urethral stump when bladder neck preservation has been successful. When the patient has had a previous transurethral resection of the prostate (TURP) or if the patient has a large median lobe, bladder neck preservation may not be entirely successful. Under these circumstances, the bladder...

Pcspes

PC-SPES is a combination of seven Chinese medicinal herbs Reishi (Ganoderma lucidum) spores, Balkal skullcap (Scutellaria baicalenesis) root, Rabdosia (Rabdosia rubescens) root, Dyer's wood (Isatis indigotica) root, mum (Dendranthema morifolium) flower, san-qi ginseng (Panax notoginseng) bark and licorice (Glycyrrhiza glabra) root with the addition of one North American herb, saw palmetto. This herbal product appeared a few years ago and is widely used by patients as a treatment for their...

Innervation Of The Male Urinary Sphincter

In the absence of an intact bladder neck, as in the case of post-RRP patients, urinary continence is dependent on the sphincter mechanism found at the level of the membranous urethra (from the prostate apex to the perineal membrane). This sphincter mechanism consists of the prostatomembranous urethra, the periurethral musculature or rhabdosphincter, and the extrinsic paraurethral musculature and connective tissue structures of the pelvis. All three intrinsic layers of the prostatomembran-ous...

The Urethra And Associate Continence Structures

In most descriptions, male continence mechanisms are divided into two continence zones the internal or proximal complex, consisting of the intraprostatic urethra and bladder neck the external complex, consisting of the urethra distal to the verumontanum the puborectalis aspect of the levator ani and the additional fascial support structures previously mentioned.20-22 The urethral component of the external complex is a sophisticated arrangement of elastic fibers, longitudinal smooth muscle and...

Embryology And Zonal Anatomy

The prostate begins to develop at approximately 8 weeks from the pelvic urethra. Epithelial outgrowths continue to grow with accompanying lumenal development. This is further modified by the effects of androgens and stromal-epithelial growth factor interactions.1,2 The prostate is an ovoid structure of fibromuscular and glandular components. It encases the urethra, which angulates at its midpoint toward the bladder neck. The gland is covered by a 0.5 mm capsule of smooth muscle and connective...

Comparative studies for localized disease

As we have established the general patterns of QOL after the three major treatments for localized disease, the question remains can we properly compare the modalities to each other As stated, no randomized trials are available and, therefore, retrospective and observational cohort studies must be interpreted, understanding the inherent weaknesses in these study designs. In addition, there are subtle points of technique that one can look for in the methods section that may shed light on the...

Urinary toxicity

Mild to moderate urinary side effects are the most common sequelae after 3D-CRT of IGTPB, typically radiation-induced urethritis or prostatitis. In 3D-CRT patients, 90 may have no or only mild (grade 1) acute genitourinary (GU) toxicity that may require no therapeutic intervention. As many as 20 may have grade 2 urinary side effects that may require medications for relief. This is in sharp contrast to IGTPB patients where no more than 60 have minimal or no GU toxicity. It is well documented...

Hadece Is How Medicine

Biopsy has a high correlation with ECE in the sextant in which there is a positive laterally directed biopsy. In a recent study at our institution involving 76 patients (23.7 of which had ECE), the presence of cancer on an individual laterally directed biopsy core was a significant predictor of ECE independent of DRE, preoperative PSA and transrectal ultrasound results (P 0.0046). However, the presence of cancer on an individual sextant biopsy core was not predictive of ECE (P 0.0525).32...

Definition Of A Positive Surgical Margin

Because the technique of specimen processing impacts on the incidence of positive surgical margins, a standard technique using 2-3 mm sections has been described by True in the hope of improving the likelihood of detecting positive margins. A positive surgical margin is defined as the presence of tumor cells at the inked surgical margin of resection. The margin extent is classified as focal, extensive or equivocal. A focal margin is defined as a margin present in only one step section and...

Treatment Of Obesity

Although it is conceptually easy to treat obesity exhort the patient to 'push away from the table' decreasing calorie intake and to adopt a healthy program of physical activity increasing energy expenditure, it is notoriously difficult to achieve sustained medically significant weight loss. Without extraordinary measures such as prison-like conditions or surgical methods, the failure rate is in excess of 90 after 1 year. Diets, exercise and behavior modification, all 'difficult methods', fail...

Transection of the bladder neck

We begin the transection at the anterior aspect of the bladder neck a few millimeters cephalad to the distal suture of the dorsal venous complex. Because of the lack of manual palpation, the identification of the bladder neck differs from open surgery. The recognition of the landmarks is facilitated by a couple of rules (Fig. 38.4). The consistency of the prostate and the bladder are totally different. The prostate is a solid gland, whereas the bladder is mobile when palpated with endoscopic...

Pin Is A Disease

Premalignant lesions that affect other organs have been identified and currently are treated when diagnosed such that the premalignant lesions itself is a disease. Treatment of these precancerous lesions would appear to be of clinical benefit notwithstanding the potential for cancer prevention. These clinical benefits would reduce morbidity, enhance quality of life, delay surgery or radiation, and increase the interval for surveillance requiring invasive procedures.25 Examples of treated...

Passive immunotherapy

Passive immunization involves administrating antibodies to the patient that will bind specific tumor antigens to kill those cells selectively. Prostate-specific membrane antigen (PSMA) is a cell surface glycoprotein expressed by prostate epithelial cells and is overexpressed in prostate cancer, including advanced stages. PSMA-specific monoclonal antibodies have been developed and may have a novel therapeutic application.81,82 Kahn and associates have recently reported on a phase II clinical...

Thomas Anderson

Office of Community Relations, Temple University, Philadelphia, PA, USA I am an African American male who was diagnosed with prostate cancer in January 1995. I have been a survivor for the past 8 years and hope to survive and see many, many more years in good health. I would like to acknowledge my loving wife, Ruth Anderson, my son, Sean Anderson, my mother, Lillian Buckins, my brother Robert, who is also a prostate cancer survivor, and other members of my family and friends for their prayers...

Indications And Contraindications

Various selection criteria are used in the recommendation for PB. Because of anatomic constraints, larger prostate volumes are a relative contraindication for permanent PB. As the volume of the prostate gland increases, the risk of pubic arch interference increases. Many investigators use a volume cut-off volume around 50 cm3 in order to select appropriate candidates for PB. However, various intraoperative techniques are possible to gain access to the prostate gland's periphery in a tightly...

Prognostic Implication Of Positive Apical Margin

The intimate anatomical relationship of the prostate to surrounding structures limits the ability to obtain wide surgical margins. Furthermore, the prostate lacks a true anatomical capsule, and normal condensation of fibromuscular tissue present in the posterolateral margin is not present at the apex.45 Stamey etal. also noted the absence of a defined capsule at the apex more than anywhere else in the prostate gland.3 McNeal suggested that cancer in the apex of the gland may represent invasion...

Indications Of

RPP is mainly performed for clinically organ-confined prostate cancer. Patients subjected to this procedure should have a projected life expectancy of at least 10-15 years. RPP in the setting of suspected extracapsular extension or as a salvage procedure following failed local radiation treatment is rarely performed for select cases only. While RPP is technically feasible in the vast majority of patients, certain features deserve consideration. These are listed below. Positioning of the patient...

New Issues In The Radical Retropubic Prostatectomy

Without a doubt, experienced prostate surgeons will identify numerous points of our technique that they perform differently. The point to emphasize for surgeons in training is that there are many ways to perform this operation that will be successful, so long as the principles of oncologic surgery are followed, while trying to minimize the side effects of incontinence and, when indicated, impotency. Again, we emphasize that careful ongoing review of one's personal pathologic and quality of life...

Lower extremity neuropraxia

Lower extremity neuropraxia is a unique problem associated with the exaggerated lithotomy position. While it is relatively common in the immediate postoperative setting occurring in up to 20 of patients, symptoms are usually transient and consist of sensory deficits below the knee only.14 These symptoms invariably resolve completely, in most cases prior to the patient's discharge from the hospital on postoperative day 2. The etiology of these injuries is mostly attributable to a stretch injury...

Challenges to linkage studies of prostate cancer

Paralleling studies of other complex diseases, segregation analyses have suggested a heterogeneous genetic etiology of inherited prostate cancer that is characteristic of complex diseases. The suggestion of multiple modes of inheritance implicates the presence of multiple genes in hereditary prostate cancer susceptibility. In linkage studies, the presence of genetic heterogeneity dramatically decreases the power to detect the effect of any single major gene when the LOD scores of multiple...

Pinatypia And Prostate Biopsy

High-grade prostatic intraepithelial neoplasia (PIN) is most likely a precursor of prostate cancer and is frequently associated with it, whereas the direct link between low-grade PIN and cancer is not established. The clinical evolution of isolated high-grade PIN has been the object of much concern because of the possibility of undiagnosed prostate cancer or the evolution of this premalignant lesion in invasive carcinoma. High-grade PIN has been identified in approximately 4-14 of prostate...

Rectal injury

Rectal injury is a well-recognized risk of radical prostate surgery. It is a potentially concerning, but rare complication of the perineal approach, with an incidence of 1-3 in the hands of experienced surgeons.7 An increased risk of rectal injury in RPP compared to RRP relates to the intimate relationship of the plane of initial dissection to the rectum. They most commonly occur at the time of dissection of the rectourethralis muscle or during placement of the posterior weighted retractor....

Section of the lateral pedicles

The periprostatic fascia has two layers the outer layer, called levator fascia, and an inner layer, called prostatic fascia. The neurovascular bundles run between these two layers (Fig. 38.5). At this point they are in proximity with the Denonvillier's fascia. If nerve-sparing is to be undertaken, the two layers of Fig. 38.5. Nerve sparing. After incision of the levator fascia, the neurovascular bundle is released of the prostate. Fig. 38.5. Nerve sparing. After incision of the levator fascia,...

Epic

The EPIC survey33 aims to improve upon the UCLA PCI survey by validating additional questions targeted at treatment-related urinary side effects from brachytherapy. In the UCLA PCI survey, the function questions only address urinary incontinence. To account for brachytherapy-related side effects, many QOL studies using the UCLA PCI have added the AUA symptom index score (AUASI), which asks questions relating to urinary frequency, hesitancy and irritation. However, the AUASI was designed and...

Support Group Awareness

After my ordeal of surviving prostate cancer, I discovered that there were many men, especially African American men, who knew someone that needed advice and education about prostate cancer and diet. I was asked by an associate who was a breast cancer survivor if I would be interested in becoming a volunteer for the American Cancer Society, to help organize a Man-To-Man prostate cancer support group for the Southeast Region of Pennsylvania Division to include Philadelphia, Pennsylvania, where I...

Urethrovesical Anastomosis

We use Ethicon needle drivers during the procedure and use the two ports on either side of the umbilicus. The authors use interrupted 2-0 polyglactin sutures on a 26-mm SH needle with intracorporeal knot tying. The 17.45-mm RB1 needle can also be used (Ethicon Inc., Somerville, NJ). The first suture is placed inside out on the urethra and outside in on the bladder with a right-hand forehand approach at the 5 o' clock position. The second stitch is a 6 o'clock stitch, which is placed right-hand...

Neurostimulationcaver Map

During radical prostatectomy it is possible to evaluate the functional capacity of the neurovascular bundles with the CaverMap Surgical Aid. This device stimulates the cavernous nerves, which will produce a 1 or greater change in the circumference of the penile shaft if the bundles are intact.23 Several studies have attempted to correlate a positive Caver-Map response with recovery of potency postoperatively.23,24 Klotz and Herschorn found 94 of patients who had a positive CaverMap response...

Implications For Prostate Cancer Treatment And Prevention

Elevated levels of circulating IGF-1, which are strongly associated with the risk of developing prostate cancer, are measured long before presentation of this cancer. IGF may be a new tool for prostate cancer risk assessment and reduction. Recent research projects indicated that current androgen-targeting therapies alter IGF physiology within androgen-responsive cells in a manner that contributes to apoptosis associated with androgen withdrawal. Several IGF binding proteins undergo an...

Surgical Procedure

Patients are admitted on an outpatient basis. They are advised to refrain from consuming anything by mouth starting from midnight before the procedure. Routine bowel preparations are not performed. A broad-spectrum antibiotic is given pre-operatively and for 48 hours after the procedure. Radical prostatectomy candidates often have a good performance status and the incidence of hypercoagulability due to malignancy is also likely to be low. The benefit of preventive measures for pulmonary embolus...

Biopsy Technique

Prostate biopsy can be performed either transperineally or transrectally, and there are advocates of both approaches. Transrectal digitally directed needle biopsy of the prostate gland was first performed in 1937.23 It was not until the early 1980s that this procedure was performed using ultrasound guidance as it is commonly done today. Since that time, many technological advances have been developed that have revolutionized the ability to examine this gland. These include the development of...

Saw palmetto

Saw palmetto is a compound derived from the fruit extract of the American dwarf palm tree that is native to the Atlantic Coastal Plain from North Carolina south through Northern Florida. The common herbal preparation represents the extracted lipids and sterols. Recent clinical trials testing saw palmetto in the treatment of benign prostatic hyperplasia (BPH) were reviewed in the Journal of the American Medical Association in 1998.45 After critically evaluating the quality of the clinical trials...

Technique Of Minilaparotomy Radical Retropubic Prostatectomy

Bilateral lower extremity sequential compression devices are placed and preoperative antibiotics are administered before induction of anesthesia. Following regional or general anesthesia, the doctor positions the patient so that the umbilicus lies just below the break in the table. Current preference is given to general anesthesia over epidural because of the slower effect of regional anesthesia and potentiation of postoperative ileus. The table is then flexed maximally to extend the distance...

The Impact Of Psa Derivates

As we know from PSA-based screening studies, approximately 9 of all asymptomatic men will have elevated serum PSA values but only about a third will have cancer detected on initial biopsy.22'23 The question is whether the 66 men with an initially negative prostate biopsy have an elevated serum PSA value because of benign prostatic hyperplasia, prostatitis or undetected cancer in their peripheral or TZ of the prostate. Keetch etal. have previously shown that cancer detection rates at biopsies...

The Pathogenesis Of Cancer

The behavior of every cell in the body is dependent on its DNA. Changes in this DNA affect the expression and function of critical genes. Altered genes result in altered mRNA expression and subsequently altered proteins. Many changes may occur however, 5-10 specific alterations are required to convert a benign into a fully malignant prostate cell.3 In a small number of prostate cancers, some of these alterations may be inherited. In the majority, however, these are acquired somatic...

Hifu On Experimental

The antineoplastic effect of HIFU has been documented in several experimental settings.5 Fry and Johnson implanted hamster medulloblastoma cells in rats, which were subsequently treated by HIFU (900 W cm2, 1 MHz, 7 seconds).9 The tumor cure rate was 29 in rats treated with HIFU and 40 in rates with a combination of HIFU and chemotherapy.9 Moore etal. and Yang etal. have studied the effect of HIFU on the Morris 3924-A hepatoma implanted into rats.10,11 The tumor volume in treated animals was...

The Scope Of The Problem In Prostate Cancer

We became aware of the problems of bone mineral density loss when, within the space of 1 year, three of the author's patients suffered hip fractures. We then began to evaluate our patients who were being treated with androgen deprivation therapy (ADT) with DEXA scans. Of our 75 patients studied to date, 70 were on leuprolide therapy and five had undergone bilateral orchiectomy.10 All patients underwent an in-office screening DEXA scan utilizing the fourth digit of the nondominant hand. When...

Surgical Techniques And Blood Loss

Meticulous surgery is by far the best option to minimize blood loss. The urological surgeon should be thoroughly familiar with the details of the vascular and neurological anatomy of the area. Historically the surgical anatomy of the area has been poorly understood. As late as 1998, Patrick Walsh, the pioneer of the modern era of prostate cancer surgery, declared 'It is humbling to realize that even today the basic anatomy may not be known or understood'.1 Beneventi and Noback were the first...

Frequency And Location Of Positive Surgical Margins

Researchers using different surgical approaches and techniques for radical prostatectomy have reported positive margins with variable frequency at different sites. Overall, the incidence of positive surgical margins in radical prostatectomy series ranges from 11 to 62 .6,11,13-20 Wieder etal. reported an overall rate of positive surgical margin after radical retropubic prostatectomy to be 28 , ranging from 10 to 59 by pathologic stage.21 The recent decline in positive surgical margins has been...

Vascular Supply And Innervation Of The Corpora Cavernosa

The arterial supply to the corpora cavernosa is usually from the internal pudendal artery via the common penile artery. The three branches of the common penile artery are the cavernosal artery, the dorsal penile artery and the bulbourethral artery. The cavernosal artery, during its course within the corpus cavernosum, gives off helicine arteries that feed the trabecular erectile tissue and sinusoids. The dorsal artery of the penis is responsible for engorgement of the glans penis. Accessory...

The Impact Of Prostate Volume

The impact of prostate volume in the decision of prostate biopsy technique and of when to perform a repeat prostate biopsy is still a matter of debate. Given that sextant prostatic systematic biopsies sample only about 90 mm of prostate tissue (6 x 15 mm cores), increased prostatic volume may significantly reduce the chance of detecting cancer.2-4 Owing to the wide variation in gland sizes and shapes, it seems logical that in smaller glands the prostate biopsy leads to a more extensive sampling...

Artificial urinary sphincter

Ray Images Prostate Cancer

The 'gold standard' therapy for sphincteric incontinence in the male is the AMS 800 (American Medical Systems, Minne-tonka, MN) artificial urinary sphincter prosthesis (Fig. 34.2). Of the available options, this device offers the greatest chance of cure from sphincteric incontinence. Previous models of the artificial urinary sphincter had considerable technical problems, including a high rate of urethral erosion.90 The introduction of the narrow-backed urethral cuff in 1987 has resulted in...

Complications

Urinary difficulties after XRT include a spectrum of complications from mild irritative voiding symptoms to severe incontinence, bladder neck or urethral strictures and hematuria. Gauging urinary complications has included standard toxicity grades on a four-point scale mild, moderate, severe, life-threatening to patient quality of life data by questionnaire, which do not always correlate. The desire to lower toxicity and complications to adjacent tissues like the bladder and rectum has...

XRT after RRP

As with salvage RRP after XRT, the patients most likely to benefit from salvage XRT after surgical treatment are those with local recurrence only, with the absence of regional or distant metastatic spread. This distinction is difficult to make, since the majority of patients typically have PSA elevation without clinically evident local or distant recurrence. Several factors have been identified to indicate local versus distant recurrence, specifically time to PSA recurrence longer then 2 years...

Black cohosh root

The alcoholic extract of black cohosh root is widely used by women in Europe and now the USA as a treatment for menopausal symptoms.54-56 Virtually all of the clinical studies have been done with one preparation, Remifemin, originally developed in Europe and now marketed in the USA. Many men with prostate cancer on hormonal therapy are using Remifemin or other black cohosh root preparations as treatment for their hot flashes and other symptoms of male menopause. Black cohosh was one of the...

Theodor Billroth Prostatectomy 1867

The development of the perineal approach to the prostate may be traced back to the 'blind' perineal lithotomies performed to treat bladder stones through a median perineal incision as early as 400 BC. Theodor Billroth is credited with the first planned perineal prostatectomy for malignancy in 1867, when he enucleated a prostate cancer through a median perineal incision.7 Meanwhile, the origin of modern perineal prostatectomy for prostate cancer dates back to Hugh Hampton Young. In 1902 he...

Periurethral injectable agents

Teflon paste, silicone, fat and collagen have all been utilized as injectable agents to provide improved continence following prostatectomy. Osther and Rohl treated 25 patients with transperineal or transurethral injection of Teflon paste with 'good to moderate' results in 24 of patients with minimal morbidity.60 The retreatment rate, however, was 72 . The patients with the worst results had poor bladder compliance. Additionally, patients that failed the initial injection were usually no better...