Problems of comorbidity in mortality after prostatectomy.

OBJECTIVE: In recent studies of patients with benign prostatic hyperplasia (BPH), men undergoing transurethral resection of the prostate (TURP) had higher long-term mortality than men undergoing open prostatectomy. We tested the hypothesis that the higher mortality for patients undergoing TURP could have occurred if these patients were older and sicker at the time of surgery than patients undergoing open prostatectomy. DESIGN AND SETTING: Retrospective cohort study at Yale-New Haven (Conn) Hospital. PATIENTS: Two hundred fifty-two men who underwent TURP or open prostatectomy from 1979 through 1981 for the treatment of BPH. MAIN OUTCOME MEASURES: Five-year mortality adjusted for age and severity of comorbid illness at the time of surgery. RESULTS: The crude 5-year mortality rates were 17.5% (22 of 126 patients) for the TURP group and 13.5% (17 of 126 patients) for the open group. At the time of surgery, however, patients in the TURP group were sicker and older than patients in the open group. As the detail and quality of the assessment of comorbidity increased, the adjusted risk of TURP decreased. Improved classifications of comorbidity in three different forms of statistical analysis did not show an effect of type of prostatectomy on long-term mortality (Mantel-Haenszel relative risk, 1.03; 95% confidence interval, 0.57 to 1.87). CONCLUSIONS: These results suggest that TURP does not increase long-term mortality after surgery for the treatment of BPH. Inadequate accounting for severity of illness may also affect other statistical "adjustments" used in research concerned with patient outcomes.

Incontinence after augmentation cystoplasty and internal diversion.

The collective published experience with continent urinary diversions, together with our own, indicates that there are certain basic principles with regard to continence, which is dependent on: (1) the pressure generated by the reservoir; (2) the outflow resistance of the outlet; and (3) detubularization, which is crucial to diminish the uninhibited involuntary bowel contractions. Detubularized ileal pouches provide the lowest pressures (less than 20 cm H2O). Although the majority of patients (approximately 85%) who have a low-pressure ileal neobladder are completely continent, a few experience persistent nocturnal incontinence as a result of low resting urethral pressure. Numerous continence methods have been described, each with its own unique set of problems. The most physiologic continence mechanism is the external urethral sphincter in men. It is clear that total continence with this mechanism is not assured. Other factors such as reservoir contractions, overflow incontinence, decreased sphincter tone, and loss of the normal vesicourethral reflex play an important role in nocturnal incontinence. However, understanding these contributing elements will allow us to refine the construction of a continent physiologic bladder substitute.

Retrograde ejaculation.

Failure of the normal ejaculatory mechanism may lead to retrograde ejaculation. This occurs most commonly as a result of transurethral prostatectomy, retroperitoneal lymph-node dissection and diabetic neuropathy. The diagnosis is based on the absence of sperm in the antegrade ejaculate and the presence of sperm in the post-masturbatory urine. If pharmacologic attempts to restore antegrade ejaculation fail, sperm recovery from the urine and intrauterine insemination are usually indicated. Surgical alternatives are discussed.

Ureteral injuries at laparoscopy: insights into diagnosis, management, and prevention.

The increasing use of laparoscopy as a therapeutic method mandates a reappraisal of the risks involved. Complications frequently described include injuries to the large and small bowels, bladder, and blood vessels. The world literature reports only eight cases of ureteral injury at laparoscopy. In this report, we present five additional cases of ureteral injury occurring at laparoscopy, in addition to a summary of those previously reported. Patients tend to present in the early postoperative period (48-72 hours) with low back pain, abdominal pain, leukocytosis, and peritonitis. The diagnosis should be made by intravenous pyelography; if possible, the injury should be stented by either the retrograde or percutaneous route. The injuries, except for one apparent trocar injury, involved the use of electrocoagulation, both unipolar and bipolar. The injuries occurred most commonly near the uterosacral ligaments. In 38% (five of 13) of the cases, the laparoscopy was performed for treatment of endometriosis. Three of the 13 patients eventually lost renal function of the affected side; two of these underwent a nephrectomy. Because visualization of the ureter near the cervix at the time of laparoscopy is difficult, especially in the presence of disease, laparoscopic procedures in this area must be carried out with caution.

Continent reservoirs.

Continent urinary diversion is a major advance in the treatment of selected patients following cystectomy. Twenty-eight patients have undergone some form of continent urinary diversion at Yale New Haven Hospital during the past three years; thirteen have a continent reservoir with a continent stoma on the abdominal wall, and empty the urine by self-intermittent catheterization, and 15 have a reservoir anastomosed to the urethra, the majority of whom void spontaneously. All are continent by day and over 50% are continent at night. A recent modification in the construction of the urinary reservoir would appear to have resolved the problem of nocturnal incontinence. The results and urodynamic studies in this group of patients are discussed, and it is concluded that a detubularized intestinal reservoir provides a safe and effective method for continent urinary diversion in selected patients following cystectomy.

Long-term experience with flutamide in patients with prostatic carcinoma.

Fifty-two patients with previously untreated metastatic carcinoma of the prostate were treated with flutamide 250 mg tid. Response was classified according to objective and subjective criteria, and duration of response and total survival were chosen as endpoints. Disease manifestations at presentation and tumor burden were studied to determine their relationship, if any, to treatment response and outcome. Total survival was longest in 26 patients who had objective responses (mean 50 months). Patients who failed to respond (n = 13) and those who had subjective responses (n = 13) survived an average of eleven and 17.2 months, respectively. Tumor burden was correlated with response to treatment and total survival; those judged to have a minimum tumor burden had objective responses and survived an average of sixty months. Sixteen other patients who had been previously treated with diethylstilbestrol were also studied. Nine of these had cardiovascular complications while taking diethylstilbestrol, and tolerated flutamide without further complications. Those in remission stayed in remission, and sexual potency returned to 5 patients.