- •Hematuria II: causes and investigation
- •Hematospermia
- •Lower urinary tract symptoms (LUTS)
- •Nocturia and nocturnal polyuria
- •Flank pain
- •Urinary incontinence in adults
- •Genital symptoms
- •Abdominal examination in urological disease
- •Digital rectal examination (DRE)
- •Lumps in the groin
- •Lumps in the scrotum
- •2 Urological investigations
- •Urine examination
- •Urine cytology
- •Radiological imaging of the urinary tract
- •Uses of plain abdominal radiography (KUB X-ray—kidneys, ureters, bladder)
- •Intravenous pyelography (IVP)
- •Other urological contrast studies
- •Computed tomography (CT) and magnetic resonance imaging (MRI)
- •Radioisotope imaging
- •Post-void residual urine volume measurement
- •3 Bladder outlet obstruction
- •Regulation of prostate growth and development of benign prostatic hyperplasia (BPH)
- •Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH
- •Benign prostatic obstruction (BPO): symptoms and signs
- •Diagnostic tests in men with LUTS thought to be due to BPH
- •Why do men seek treatment for their symptoms?
- •Watchful waiting for uncomplicated BPH
- •Medical management of BPH: combination therapy
- •Medical management of BPH: alternative drug therapy
- •Minimally invasive management of BPH: surgical alternatives to TURP
- •Invasive surgical alternatives to TURP
- •TURP and open prostatectomy
- •Indications for and technique of urethral catheterization
- •Indications for and technique of suprapubic catheterization
- •Management of nocturia and nocturnal polyuria
- •High-pressure chronic retention (HPCR)
- •Bladder outlet obstruction and retention in women
- •Urethral stricture disease
- •4 Incontinence
- •Causes and pathophysiology
- •Evaluation
- •Treatment of sphincter weakness incontinence: injection therapy
- •Treatment of sphincter weakness incontinence: retropubic suspension
- •Treatment of sphincter weakness incontinence: pubovaginal slings
- •Overactive bladder: conventional treatment
- •Overactive bladder: options for failed conventional therapy
- •“Mixed” incontinence
- •Post-prostatectomy incontinence
- •Incontinence in the elderly patient
- •Urinary tract infection: microbiology
- •Lower urinary tract infection
- •Recurrent urinary tract infection
- •Urinary tract infection: treatment
- •Acute pyelonephritis
- •Pyonephrosis and perinephric abscess
- •Other forms of pyelonephritis
- •Chronic pyelonephritis
- •Septicemia and urosepsis
- •Fournier gangrene
- •Epididymitis and orchitis
- •Periurethral abscess
- •Prostatitis: presentation, evaluation, and treatment
- •Other prostate infections
- •Interstitial cystitis
- •Tuberculosis
- •Parasitic infections
- •HIV in urological surgery
- •6 Urological neoplasia
- •Pathology and molecular biology
- •Prostate cancer: epidemiology and etiology
- •Prostate cancer: incidence, prevalence, and mortality
- •Prostate cancer pathology: premalignant lesions
- •Counseling before prostate cancer screening
- •Prostate cancer: clinical presentation
- •PSA and prostate cancer
- •PSA derivatives: free-to-total ratio, density, and velocity
- •Prostate cancer: transrectal ultrasonography and biopsies
- •Prostate cancer staging
- •Prostate cancer grading
- •General principles of management of localized prostate cancer
- •Management of localized prostate cancer: watchful waiting and active surveillance
- •Management of localized prostate cancer: radical prostatectomy
- •Postoperative course after radical prostatectomy
- •Prostate cancer control with radical prostatectomy
- •Management of localized prostate cancer: radical external beam radiotherapy (EBRT)
- •Management of localized prostate cancer: brachytherapy (BT)
- •Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU
- •Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0)
- •Management of advanced prostate cancer: hormone therapy I
- •Management of advanced prostate cancer: hormone therapy II
- •Management of advanced prostate cancer: hormone therapy III
- •Management of advanced prostate cancer: androgen-independent/ castration-resistant disease
- •Palliative management of prostate cancer
- •Prostate cancer: prevention; complementary and alternative therapies
- •Bladder cancer: epidemiology and etiology
- •Bladder cancer: pathology and staging
- •Bladder cancer: presentation
- •Bladder cancer: diagnosis and staging
- •Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease
- •Muscle-invasive bladder cancer: radical and palliative radiotherapy
- •Muscle-invasive bladder cancer: management of locally advanced and metastatic disease
- •Bladder cancer: urinary diversion after cystectomy
- •Transitional cell carcinoma (UC) of the renal pelvis and ureter
- •Radiological assessment of renal masses
- •Benign renal masses
- •Renal cell carcinoma: epidemiology and etiology
- •Renal cell carcinoma: pathology, staging, and prognosis
- •Renal cell carcinoma: presentation and investigations
- •Renal cell carcinoma: active surveillance
- •Renal cell carcinoma: surgical treatment I
- •Renal cell carcinoma: surgical treatment II
- •Renal cell carcinoma: management of metastatic disease
- •Testicular cancer: epidemiology and etiology
- •Testicular cancer: clinical presentation
- •Testicular cancer: serum markers
- •Testicular cancer: pathology and staging
- •Testicular cancer: prognostic staging system for metastatic germ cell cancer
- •Testicular cancer: management of non-seminomatous germ cell tumors (NSGCT)
- •Testicular cancer: management of seminoma, IGCN, and lymphoma
- •Penile neoplasia: benign, viral-related, and premalignant lesions
- •Penile cancer: epidemiology, risk factors, and pathology
- •Squamous cell carcinoma of the penis: clinical management
- •Carcinoma of the scrotum
- •Tumors of the testicular adnexa
- •Urethral cancer
- •Wilms tumor and neuroblastoma
- •7 Miscellaneous urological diseases of the kidney
- •Cystic renal disease: simple cysts
- •Cystic renal disease: calyceal diverticulum
- •Cystic renal disease: medullary sponge kidney (MSK)
- •Acquired renal cystic disease (ARCD)
- •Autosomal dominant (adult) polycystic kidney disease (ADPKD)
- •Ureteropelvic junction (UPJ) obstruction in adults
- •Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation
- •Renal duplications
- •8 Stone disease
- •Kidney stones: epidemiology
- •Kidney stones: types and predisposing factors
- •Kidney stones: mechanisms of formation
- •Evaluation of the stone former
- •Kidney stones: presentation and diagnosis
- •Kidney stone treatment options: watchful waiting
- •Stone fragmentation techniques: extracorporeal lithotripsy (ESWL)
- •Intracorporeal techniques of stone fragmentation (fragmentation within the body)
- •Kidney stone treatment: percutaneous nephrolithotomy (PCNL)
- •Kidney stones: open stone surgery
- •Kidney stones: medical therapy (dissolution therapy)
- •Ureteric stones: presentation
- •Ureteric stones: diagnostic radiological imaging
- •Ureteric stones: acute management
- •Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone
- •Ureteric stone treatment
- •Treatment options for ureteric stones
- •Prevention of calcium oxalate stone formation
- •Bladder stones
- •Management of ureteric stones in pregnancy
- •Hydronephrosis
- •Management of ureteric strictures (other than UPJ obstruction)
- •Pathophysiology of urinary tract obstruction
- •Ureter innervation
- •10 Trauma to the urinary tract and other urological emergencies
- •Renal trauma: clinical and radiological assessment
- •Renal trauma: treatment
- •Ureteral injuries: mechanisms and diagnosis
- •Ureteral injuries: management
- •Bladder and urethral injuries associated with pelvic fractures
- •Bladder injuries
- •Posterior urethral injuries in males and urethral injuries in females
- •Anterior urethral injuries
- •Testicular injuries
- •Penile injuries
- •Torsion of the testis and testicular appendages
- •Paraphimosis
- •Malignant ureteral obstruction
- •Spinal cord and cauda equina compression
- •11 Infertility
- •Male reproductive physiology
- •Etiology and evaluation of male infertility
- •Lab investigation of male infertility
- •Oligospermia and azoospermia
- •Varicocele
- •Treatment options for male factor infertility
- •12 Disorders of erectile function, ejaculation, and seminal vesicles
- •Physiology of erection and ejaculation
- •Impotence: evaluation
- •Impotence: treatment
- •Retrograde ejaculation
- •Peyronie’s disease
- •Priapism
- •13 Neuropathic bladder
- •Innervation of the lower urinary tract (LUT)
- •Physiology of urine storage and micturition
- •Bladder and sphincter behavior in the patient with neurological disease
- •The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
- •Bladder management techniques for the neuropathic patient
- •Catheters and sheaths and the neuropathic patient
- •Management of incontinence in the neuropathic patient
- •Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
- •Management of hydronephrosis in the neuropathic patient
- •Bladder dysfunction in multiple sclerosis, in Parkinson disease, after stroke, and in other neurological disease
- •Neuromodulation in lower urinary tract dysfunction
- •14 Urological problems in pregnancy
- •Physiological and anatomical changes in the urinary tract
- •Urinary tract infection (UTI)
- •Hydronephrosis
- •15 Pediatric urology
- •Embryology: urinary tract
- •Undescended testes
- •Urinary tract infection (UTI)
- •Ectopic ureter
- •Ureterocele
- •Ureteropelvic junction (UPJ) obstruction
- •Hypospadias
- •Normal sexual differentiation
- •Abnormal sexual differentiation
- •Cystic kidney disease
- •Exstrophy
- •Epispadias
- •Posterior urethral valves
- •Non-neurogenic voiding dysfunction
- •Nocturnal enuresis
- •16 Urological surgery and equipment
- •Preparation of the patient for urological surgery
- •Antibiotic prophylaxis in urological surgery
- •Complications of surgery in general: DVT and PE
- •Fluid balance and management of shock in the surgical patient
- •Patient safety in the operating room
- •Transurethral resection (TUR) syndrome
- •Catheters and drains in urological surgery
- •Guide wires
- •JJ stents
- •Lasers in urological surgery
- •Diathermy
- •Sterilization of urological equipment
- •Telescopes and light sources in urological endoscopy
- •Consent: general principles
- •Cystoscopy
- •Transurethral resection of the prostate (TURP)
- •Transurethral resection of bladder tumor (TURBT)
- •Optical urethrotomy
- •Circumcision
- •Hydrocele and epididymal cyst removal
- •Nesbit procedure
- •Vasectomy and vasovasostomy
- •Orchiectomy
- •Urological incisions
- •JJ stent insertion
- •Nephrectomy and nephroureterectomy
- •Radical prostatectomy
- •Radical cystectomy
- •Ileal conduit
- •Percutaneous nephrolithotomy (PCNL)
- •Ureteroscopes and ureteroscopy
- •Pyeloplasty
- •Laparoscopic surgery
- •Endoscopic cystolitholapaxy and (open) cystolithotomy
- •Scrotal exploration for torsion and orchiopexy
- •17 Basic science of relevance to urological practice
- •Physiology of bladder and urethra
- •Renal anatomy: renal blood flow and renal function
- •Renal physiology: regulation of water balance
- •Renal physiology: regulation of sodium and potassium excretion
- •Renal physiology: acid–base balance
- •18 Urological eponyms
- •Index
222 CHAPTER 6 Urological neoplasia
Postoperative course after radical prostatectomy
Patients are generally hospitalized for 24–48 hours and maintain Foley catheter drainage for 10–14 days. The robotically assisted laparoscopic prostatectomy (RALP) is associated with reduced blood loss and more rapid discharge from the hospital. Currently, there are no convincing data that the long-term functional and oncological outcomes are improved by the less invasive robotically assisted laparoscopic approach.
Complications of radical prostatectomy
General complications
These include those of any major surgery: bleeding requiring reoperation and/or transfusion; infection; thromboembolism; and cardiopulmonary complications or disturbance. These are minimized by attention to hemostasis, prophylactic antimicrobials, pneumatic calf compression, low-dose heparin postoperatively, and early mobilization.
Specific complications—early
Intraoperative obturator nerve, ureteral, or rectal injury (all rare) should be managed immediately if recognized, with end-to-end nerve anastomosis; ureteral reimplantation; or primary three-layer rectal closure with or without a temporary loop colostomy.
Postoperative catheter displacement (rare) is managed with careful replacement using cystoscopic guidance over a wire if there are any concerns over the integrity of the anastamosis. If beyond 3–5 days postoperatively, a urethrogram may reveal no leak and the catheter may not need be replaced.
Postoperative urine or lymphatic leak (distinguished by fluid creatinine concentration) through drains (occasional) is managed by prolonged catheter and wound drainage; lymphatic leaks may require sclerotherapy with tetracycline.
Lymphocele (encapsulated collection of lymphatic fluid) can cause lower extremity swelling or abdominal discomfort. It is unusual with the RALP as the peritoneum is usually opened. Lymphocele can be sclerosed or drained intraperitoneally by a laparoscopic approach.
Specific complications—late
Erectile dysfunction (ED) affects >50% of patients who were potent preoperatively; spontaneous erections may return up to 3 years postoperatively. Men >65 years or with pre-existing ED are more likely to suffer long term.
From 40% to 70% respond to oral PDE5 inhibitors at 6 months, while others require intraurethral or intracavernosal prostaglandin E1 treatments, a vacuum device, or (rarely) a prosthesis. Penile rehabilitation protocols (immediate use of PDE5 inhibitors, vacuum devices, or prostaglandins) may enhance the return of spontaneous erectile function.
POSTOPERATIVE COURSE AFTER RADICAL PROSTATECTOMY 223
Incontinence (stress-type) requiring >1 pad/day affects 5% of patients beyond 6 months and is due to injury of the external urethral sphincter during division and hemostatic control of the dorsal vein complex. The predisposing factors include age >65 years and excessive intraoperative blood loss.
Pelvic floor exercises (Kegel exercises) and the use of biofeedback techniques can help the return of continence. Periurethral bulking injections or implantation of an artificial urinary sphincter are occasionally necessary.
The use of male urethral slings has gained popularity. Incontinence may also develop secondary to bladder neck stenosis or detrusor instability; flow rates, post-void residual measurement, urodynamics, and cystoscopy may help.
Bladder neck stenosis (bladder neck contracture) affects 5–8% of patients and typically occurs 2–6 months postoperatively, rarely becoming a recurrent problem. Predisposing factors include heavy bleeding, postoperative urinary leak, and previous TURP.
Patients complain of new voiding difficulties, and treatment is by endoscopic bladder neck incision with a laser, cold knife, or electrocautery. Occasionally, chronic dilation may be necessary.
224 CHAPTER 6 Urological neoplasia
Prostate cancer control with radical prostatectomy
While there are no randomized studies comparing RP outcomes to those of radiotherapy, a randomized study comparing RP to watchful waiting has demonstrated a 40% reduction in death due to prostate cancer and a significant reduction in local and metastatic progression in the RP group with a mean follow-up of 8.2 years.1 High-grade cancers were excluded from this trial, though nonrandomized data suggest that more patients with Gleason 7–10 localized disease survive 10 years following RP than with watchful waiting or radiotherapy.
Excellent long-term results are seen in well-selected patients following RP, particularly those with organ-confined disease and prior lower urinary tract symptoms from bladder outflow obstruction. Serum PSA is usually measured at least 6–12 weeks postoperatively, then every 6 months; it should fall to <0.2 ng/mL.
The 10-year PSA progression rate following RP (usually defined as a serum PSA >0.2 ng/mL) is about 2–30%. Of these, the majority will fail within 3 years of RP. Without additional treatment, the time to development of clinical disease after PSA progression averages 8 years.2
A 20-year clinical disease-free survival of 60% is reported.3 Outcome following radical prostatectomy correlates with Gleason score; preoperative PSA; pathological T stage; and surgical margin status.
Progression-free probabilities are shown in Table 6.5.
Neoadjuvant hormone therapy given 3 or more months prior to RP does not alter the PSA progression rate, despite reducing the incidence of positive surgical margins, and is not routinely used.
Two large studies have demonstrated that adjuvant radiation therapy in the setting of adverse pathology can greatly reduce the rate of PSA progression following radical prostatectomy. SWOG 8794 demonstrated a 50% reduction in PSA recurrence in patients with positive surgical margins who received adjuvant radiation therapy.4
Similarly, in EORTC 22911, adjuvant RT improved progression-free survival from 74% to 52.6%.5 Neither study has yet demonstrated an absolute survival advantage.
1 Holmberg L, et al. (2002). A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med 347:781–789. An update has been published: BillAxelson A, Holmberg L, Ruutu M, et al. (2005). Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 352:1977–1984.
2 Pound CR, Partin AW, Eisenberger MA, et al. (1999). Natural history of progression after PSA elevation following radical prostatectomy. JAMA 281:1591–1597.
3 Swanson GP, Riggs MW, Earle JD (2002). Long-term follow-up of radical retropublic prostatectomy for prostate cancer. Eur Urol 42:212–216.
4 Swanson GP, Hussey MA, Tangen CM, et al. (2007). Predominant treatment failure in postprostatectomy patients is local: analysis of patterns of treatment failure in SWOG 8794. J Clin Oncol. 25(16):2225–2229.
5 Bolla M, Van Poppel H, Collette L (2007). Preliminary results for EORTC trial 22911: radical prostatectomy followed by postoperative radiotherapy in prostate cancers with a high risk of progression. Cancer Radiother 11(6–7):363–369.
PROSTATE CANCER CONTROL WITH RADICAL PROSTATECTOMY 225
Table 6.5 Progression-free and metastasis-free survival after open retropubic RP without adjuvant therapy, probability (%)
|
Progression- |
Progression- |
Disease- |
Metastasis- |
|
|
|
free, 5 years |
free,10 years |
specific, |
free, |
|
|
|
|
|
10 years |
10 years |
|
|
|
|
|
|
|
|
|
Gleason 2–4 |
90 |
88 |
94 |
87 |
|
|
Gleason 5–6 |
84 |
79 |
80 |
68 |
|
|
Gleason 7 |
60* |
56* |
80 |
68 |
|
|
Gleason 8–10 |
49 |
— |
77 |
52 |
|
|
PSA <4 |
91 |
|
|
|
|
|
PSA 4–9.9 |
87 |
|
|
|
|
|
PSA 10–19.9 |
70 |
|
|
|
|
|
PSA 20–50 |
50 |
|
|
|
|
|
PT1–2 |
|
93 |
|
|
|
|
PT3a |
|
76 |
|
|
|
|
PT3b |
|
37 |
|
|
|
|
|
|
|
|
|
||
N† |
|
7 |
|
|
|
|
|
|
|
|
|
||
Margin clear |
|
81 |
|
|
|
|
Margin positive |
|
36+ |
|
|
|
|
|
|
|
|
|
|
|
* 3+4 = 7 fares better than 4+3 = 7.
† Only 40–50% of patients with a positive surgical margin after RP develop a rising PSA
Management of biochemical relapse post-RP
The definition of PSA recurrence following RP is generally agreed to be a PSA of >0.3 ng/mL and rising. DRE should be performed in case there is a nodule. Biopsy of the vesicourethral anastomosis is not widely practiced unless there is a palpable abnormality.
Studies have shown that MRI and bone scans are rarely helpful in searching for metastatic disease unless the PSA is >7 ng/mL.
Current management options include observation, pelvic radiotherapy, or hormone therapy. A good response to pelvic radiotherapy is likely with the following:
•Positive surgical margins at the time of the RP
•PSA rise is delayed >1 year
•PSA doubles in >10 months
•PSA is <1 ng/mL at the initiation of radiation
•The original disease was low grade and low stage
•The radiation dose exceeds 64 Gy
If the PSA never falls below 0.2 or it rises in the first year with a doubling time of <10 months, the response to pelvic radiotherapy is less effective. It is likely in these circumstances that micrometastatic disease is present, and some form of androgen ablation therapy is usually recommended.