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Keywords:

  • prostate cancer;
  • radical prostatectomy;
  • urinary symptoms

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

OBJECTIVE

To evaluate the change in flow patterns and urinary symptoms before and after radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

Between 1994 and 1998 one surgeon undertook RRP in 125 men. Urinary flow rates and the International Prostate Symptom Score (IPSS) were recorded before and at each visit after RRP; only voids of> 150 mL were included. Strictures and bladder neck stenoses requiring surgical intervention were noted. Statistical significance was determined using Student's t or the chi-squared test.

RESULTS

Before RRP 38% men had a flow rate of ≤ 10 mL/s, suggesting obstruction. At the first review (median 2 months) there was an increase in flow rate (median 16.8 vs 11.6 mL/s, P < 0.001) and at the 6-, 14- and 20-month visits this improved further, to 20, 21 and 24 mL/s, respectively. Before RRP 56% of men had moderate or severe symptoms, with an IPSS of ≥ 8. At 2, 6, 14 and 20 months the proportion of men with an IPSS of ≥ 8 decreased to 26%, 14.5%, 18% and 14% (P < 0.001); 20% developed stricture/stenosis and initially these men had a decrease in flow rate and a higher IPSS. Their symptoms improved when the stricture was treated.

CONCLUSIONS

Two-fifths of men with prostate cancer undergoing RRP have bladder outlet obstruction, as defined by a flow rate of < 10 mL/s and bothersome symptoms. This study showed that there is a very significant increase in flow rate and decrease in IPSS after surgery. RRP offers improved voiding function and urinary symptoms, and the possibility of curing the cancer.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Prostate cancer is likely to remain one of the most important issues in men's health for the foreseeable future; it is the second or third most common cause of cancer-related death in Western men [1,2]. Treatment options include watchful waiting, androgen deprivation, external beam radiotherapy, brachytherapy and radical surgery. Despite many years of treating prostate cancer, there is no ‘best’ treatment in terms of efficacy [3]. Thus quality-of-life issues need to be considered when deciding on the best option for any particular patient. Most men with organ-confined prostate cancer who are < 70 years old and with a life-expectancy of> 10 years will be offered, and will accept, some form of curative treatment, either surgery, external beam radiotherapy or brachytherapy. Much has been made of the issues of incontinence and impotence as quality-of-life outcomes in these patients. However, irritative and obstructive voiding symptoms are also common in these men and significantly affect their quality of life [4–6], with BOO and detrusor overactivity in many patients before treatment [7,8]. This reflects the high incidence of BPH in men with prostate cancer. Neither external beam radiotherapy nor brachytherapy reduce the obstruction, and moderate/severe symptoms are regarded as a contraindication to brachytherapy. Thus, in addition to incontinence, it is important to consider the effect that any a particular treatment option may have on irritative/obstructive voiding symptoms. In the present study we sought to address this issue in patients undergoing radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Between 1994 and 1998 one surgeon undertook RRP in 125 men (median age 63 years, range 41–72; median PSA 8.3 ng/mL, range 1–45). The urinary flow rates and IPSS were recorded before and at each visit after RRP; only voids of> 150 mL were included. The timing of the visits varied and therefore to summarize the data the changes in flow and IPSS are expressed at the median follow-up for each assessment. Strictures and bladder neck stenoses requiring surgical intervention were noted at each follow-up visit. A few patients who did not have organ-confined disease had radiotherapy to the prostate bed.

Statistical significance was determined using Student's t or the chi-squared test. Not all patients attended for four follow-up visits during the study and thus data allowing paired comparisons before and after RRP were available for 108, 102, 70 and 30 patients at the first, second, third and fourth assessments, respectively. However, there was no significant difference in the flow rates or IPSS in these different groups before RRP and therefore each would appear to be representative of the whole.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Before RRP, 38% of the men had a maximum flow rate (Qmax) of ≤ 10 mL/s, suggesting obstruction. At the first follow-up (median 2 months) there was a very significant improvement in Qmax (median 11.6 vs 16.8 mL/s). At subsequent visits (median 6, 14 and 20 months) the improvement increased to 20, 21 and 24 mL/s, respectively (Fig. 1a). If the patients are arbitrarily divided into two groups (Fig. 1b; an initial Qmax of> or ≤ 10 mL/s) then there was a significant improvement in both groups. At the first assessment after RRP there was no significant difference in the median values (19.7 vs 15.7 mL/s; P = 0.18).

imageimageimageimage

Figure 1. Changes in: a, Qmax; b, Qmax for patients categorised by an initial flow of ≥ 10 mL/s (open) or < 10 mL/s (red shaded); c, IPSS; and d, IPSS categorised by initial mild (< 8, open boxes) or moderate/severe (≥ 8, red shaded) symptoms. Data for paired comparisons with the initial values were available for 108, 102, 70 and 30 patients at the four visits, respectively. For each follow-up the range (bars), quartiles (boxes) and median (central black line) are shown. *P < 0.001.

Before RRP 57% of men had an IPSS of ≥ 8, and at 2, 6, 14 and 20 months this proportion decreased to 26%, 14.5%, 18% and 14% (P < 0.001). The mean IPSS before and at 2, 6, 14 and 20 months is shown in Fig. 1c. When the group was divided into those with initially mild (IPSS < 8) or moderate/severe symptoms (IPSS ≥ 8) there was no change in the former but a significant reduction in the latter (Figure 1d).

A fifth of men developed strictures or stenoses requiring surgery; they had a significant decrease in Qmax and increase in IPSS at the first visit, and were included in the analysis before the strictures were treated. Their symptoms improved after treating the stricture. Most of the stenoses were at the bladder neck and were treated by dilatation or bladder neck incision between the first and second assessments. Two patients had urethral strictures, one eventually requiring a urethroplasty. Treating the stenoses between the first and second assessment partly explains the improvement in both flow and IPSS in that period, although even in men with no stenoses the improvement continued between the first and subsequent visits.

At the first follow-up 17% of men had a PSA of> 0.1 ng/mL, implying residual tumour; by the third and fourth visits this had increased to 20%. Of these men, 13 received radiotherapy to the prostate bed during the follow-up. Radiotherapy caused no deterioration in either the IPSS or Qmax. At no follow-up assessment was there any significant difference between the flow rate or the IPSS between those with an undetectable PSA and those with an increasing PSA level (whether the patients had received radiotherapy or not).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

With experience, the incidence of life-threatening morbidity after RRP has become rare, and there were no perioperative deaths or bowel perforations in the present patients. During the study there was a significant decrease in the incidence of positive margins as patient selection improved. This study, like others [4], shows that RRP is a good treatment option in men with moderate to severe urinary symptoms and organ-confined prostate cancer. Up to 40% of all men undergoing RRP will be in this category [4]. Few studies have compared voiding symptoms in patients treated with radiotherapy or RRP [9], or with watchful waiting [6]; in these studies the voiding symptoms are better in the group treated with RRP. In the present series, men with very mild urinary symptoms had no change, or even a slight improvement, after surgery, although others have not found this [4]. The stricture rate of 20% is at the higher end of the accepted range, but men with continuing symptoms underwent flexible cystoscopy and therefore more strictures were probably detected, as they were sought more intensely. Most strictures had formed by the first follow-up visit. Treatment for stenoses was by bladder neck dilatation or incision and the response appeared to be durable. Patients whose IPSS did not improve after RRP may have a stenosis and should undergo flexible cystoscopy.

That the improvement in symptoms and flow rate in those with an increasing PSA level (with or without radiotherapy) is maintained is important, implying that good local control is maintained in the prostate bed after RRP. This compares with the high incidence of surgical intervention for obstructive symptoms even in the immediate treatment arm of the MRC study [10].

The IPSS does not include domains assessing urinary incontinence directly, although incontinence will affect the quality-of-life question of the IPSS. Both incontinence and voiding symptoms affect the quality of life after radical treatment, and it is difficult to quantify how important either of these domains is for each patient. Steineck et al.[6] compared watchful waiting with RRP, reporting that whilst the incidence of obstructive symptoms was lower after RRP the overall distress from urinary symptoms was 27% in the RRP group and 18% in the watchful-waiting group. This implies that incontinence is more important overall in compromising the quality of life. However, this situation may differ in those with significant symptoms caused by BOO before treatment and who are excluded from brachytherapy, and in whom external beam radiotherapy will not relieve the obstruction. In this group (40% of those undergoing RRP) the relief of obstruction that is achieved by RRP may be the most important determinant of quality of life afterward. RRP offers better voiding function and urinary symptoms, and the possibility of cure from prostate cancer.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  • 1
    Black RJ, Bray F, Ferlay J, Parkin DM. Cancer incidence and mortality in the European Union: cancer registry data and estimates of national incidence for 1990. Eur J Cancer 1997; 33: 9916
  • 2
    Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin 2000; 50: 733
  • 3
    Lu-Yao G, Albertsen PC, Stanford JL, Stukel TA, Walker-Corkery ES, Barry MJ. Natural experiment examining impact of aggressive screening and treatment on prostate cancer mortality in two fixed cohorts from Seattle area and Connecticut. BMJ 2002; 325: 740
  • 4
    Schwartz EJ, Lepor H. Radical prostatectomy reduces symptom scores and improves quality of life in men with moderate and severe lower urinary tract symptoms. J Urol 1999; 161: 11858
  • 5
    Hollenbeck BK, Lipp ER, Hayward RA, Montie JE, Schottenfeld D, Wei JT. Concurrent assessment of obstructive/irritative urinary symptoms and incontinence after radical prostatectomy. Urology 2002; 59: 38993
  • 6
    Steineck G, Helgesen F, Adolfsson J et al. Quality of life after radical prostatectomy or watchful waiting. N Engl J Med 2002; 12: 7906
  • 7
    Masters JG, Robson WA, Hamdy FC. Radical prostatectomy. do pre-operative urodynamic findings help predict outcome? Aust NZ Surg 1999; 69 (Suppl): A96
  • 8
    Kleinhans B, Gerharz E, Melekos M, Weingartner K, Kalble T, Riedmiller H. Changes of urodynamic findings after radical retropubic prostatectomy. Eur Urol 1999; 35: 21721
  • 9
    Brandeis JM, Litwin MS, Burnison CM, Reiter RE. Quality of life outcomes after brachytherapy for early stage prostate cancer. J Urol 2000; 163: 8517
  • 10
    Anonymous. Immediate versus deferred treatment for advanced prostatic cancer. initial results of the Medical Research Council Trial. The Medical Research Council Prostate Cancer Working Party Investigators Group. Br J Urol 1997; 79: 23546
Abbreviations
RRP

radical retropubic prostatectomy

Qmax

maximum urinary flow rate.