Preoperative Counseling

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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 motivated and with evidence of family longevity. Patients with comorbid factors often require consultation from medical colleagues for assessment on optimization for surgery.

Theoretically, one could spend an entire office day talking about prostate cancer with a handful of patients. Unfortunately, this is not a financially viable option in today's health care market. In addition, it is our experience that localized prostate cancer is the most frequent second or more opinion visit in a urologic oncologist's practice. Therefore, streamlined patient information is a must, so that face-to-face time can be efficient. We have found it useful to produce a videotape of our oncologists discussing the treatment options for localized prostate cancer. Handouts and suggested print and Internet-based reading are also helpful. Our view of the urologist role is to provide unbiased interpretation of the information concerning the pros and cons of prostate cancer treatment options.4 We routinely recommend that our patients discuss their treatment options with a radiation oncologist, and reassure them that a 2-3-month delay in treatment while seeking the necessary medical opinions and reading is beneficial to their long-term satisfaction with treatment and is unlikely to decrease their chances of a cure, given the extremely slow growth of the tumor. There is no clear evidence to suggest that beginning androgen deprivation while the undecided patient reviews treatment options is beneficial.

It is our practice and recommendation that review of prostate biopsy slides with a designated genitourinary pathologist is a critical step in quality assurance, and maximizing accuracy of preoperative planning.5 Given that radiation therapy and brachytherapy are competitive treatment alternatives, urologists performing radical prostatectomy have a duty to review and adjust their technique periodically to maximize their results. As Gleason scoring has a learning curve and subjective component, re-review by a genitourinary pathologist may change the score in a significant number of cases. As Gleason score is a major determinant in predicting pathologic stage, relying on outside pathologist scoring allows potentially significant inconsistency when interpreting one's pathologic organ-confined and margin-free rates. Furthermore, a significant change in Gleason score may alter one's recommendations regarding watchful waiting, brachytherapy, neoadjuvant androgen deprivation or the appropriateness of nerve-sparing surgery. Finally, in rare circumstances, the presence of tumor cannot be confirmed and one of the mimics of cancer is diagnosed.

We do not obtain whole body nuclear bone scanning or computed tomography (CT) of the abdomen and pelvis for Gleason 7 or less, PSA <10, and stage T2a or less. Use of the prostascint scan has waned recently owing to the frequently equivocal results, but may be considered in higher risk cases -usually in the circumstance where external beam radiation therapy (XRT) with the long-term neoadjuvant hormone ablation is the primary treatment consideration.

The criteria of PSA < 10, PSA <7 and stage < T2a have been used to eliminate the dissection of pelvic lymph nodes in conjunction with radical perineal prostatectomy.6 We have started to adopt this approach with the radical retropubic operation as well. Our patients usually predonate 2 units of autologous blood for their procedure, although there is increasing evidence that this is not necessary. Other strategies have been described such as using only banked blood if one's transfusion rates are low, hemodilution and preoperative erythropoetin.7

Informed consent is carried out, quoting a <1% operative mortality and a <5% risk of major/minor complications.8 Quality of life literature is cited, including our own experience with radical prostatectomy, brachytherapy and XRT.9

A common issue for many men is the appropriateness of nerve preservation, while also controlling cancer. Positive surgical margins increase the risk of PSA recurrence and need for additional treatments,10 and the neurovascular bundle is a common site of spread of disease. Many factors affect return of potency following radical prostatectomy including age, number of bundles preserved and presurgical potency.11 In addition, preservation of both nerves (and for some patients under 55 years of age unilateral nerve sparing) is required for response to Sildenafil.12'13 It has been suggested that nerves may be preserved in the majority of men with potentially curable disease, and that intraoperative findings can guide the decision based upon induration in the lateral pelvic fascia, adherence of the neurovascular bundle to the prostate while it is being released, and inadequate tissue covering the postero-lateral surface of the prostate once the prostate had been removed, leading to secondary wide excision of the neurovascular bundle.14 Other authors have shown poor sensitivity of intraoperative findings.15

In our practice, we do not see a high volume of men self-selecting for nerve sparing, and have used the procedure less frequently. In the past 5 years, the distribution has been 50% non-nerve sparing, 27% unilateral nerve sparing and 23% bilateral nerve sparing. In general, nerve sparing is not performed in men with preoperative poor sexual function, men who stress that survival is the overwhelming first priority, apical induration or positive-biopsy perineural infil-tration,16,17 and in the majority of men over age 70. Nevertheless, these are only guidelines. Multiple preoperative factors affect the chance of non-organ-confined disease and positive margins, including PSA, Gleason score, stage, perineural invasion, number/percentage positive cores, length of core involvement and volume of Gleason 4/5 disease. Graefen et al. have performed a multivariate analysis of these factors, and found that the risk of extracapsular extension was significantly affected by the presence of Gleason 4 in biopsy cores, the percentage of positive cores and PSA.18 Ultimately, the risks and benefits of nerve preservation must be discussed with the patient and the decision individualized. Patients seeking multiple urologic opinions, as well as urology residents and fellows working with different experienced surgeons, will note varied attitudes and recommendations regarding nerve sparing.

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