ISSN 1677-5538 International Braz J Urol Official Journal of the Brazilian Society of Urology Volume 29, Number 4, July - August, 2003 XXX Brazilian Congress of Urology October 23-28, 2005 - Brasília - DF www.brazjurol.com.br Full Text Online Access Available International Braz J Urol EDITORS COMMENT The July August 2003 issue of the International Braz J Urol presents interesting contributions and the Editor will highlight some important papers. Doctors Holzbeierlein and colleagues, from University of Kansas Medical Center, Kansas City and Medical College of Wisconsin, Milwaukee, USA, authored on page 291 a through presentation on case selection and outcome of radical perineal prostatectomy in localized prostate cancer. It was emphasized that proper patient selection is critical to the success of the procedure and the minimization of complications. The authors concluded that radical perineal prostatectomy has stood the test of time, with only a few technical modifications since its original description more than 100 years ago. The procedure offers outcomes similar to radical retropubic prostatectomy, the standard approach for the treatment of localized prostate cancer. Its advantages include decreased pain, blood loss, and convalescence, the same arguments currently being made in favor of laparoscopic prostatectomy. Doctors Srougi and co-workers, from Federal University of São Paulo, Brazil, presented on page 336 a modification of the radical cystectomy technique with preservation of sexual function and urinary continence. The authors stated that the proposed maneuvers allow the performance of radical cystectomy with integral preservation of distal urethral sphincter and of cavernous neurovascular bundles, without jeopardizing the oncological principles. Doctor Mark S. Soloway, from University of Miami School of Medicine, Doctors John F. Ward and Horst Zincke, from Mayo Medical School, Rochester, and Doctor James E. Montie, from University of Michigan, Ann Arbor, USA, provided important editorial comments that emphasize critical points and give adequate balance on this proposed technique. Doctors Der Horst and colleagues, from University Hospitals of Kiel and University of Mannheim, Germany, presented on page 332 a 2 institutions work on a slightly modified technique of the original Schroeder-Essed plication procedure for congenital penile deviation. The modification of the technique with inverted sutures described previously consisted of horizontal incisions in the tunica albuginea. The results indicated that this simple modification offered good functional and cosmetic results and most patients were satisfied with the penile angle correction outcomes. Doctor Drogo Montague, from The Cleveland Clinic Foundation, Ohio, USA, provided an editorial comment on this article, highlighting critical points. 289 EDITORS COMMENT - continued Doctors Tobias-Machado and colleagues from ABC Medical School, São Paulo, Brazil, presented on page 313 a comparative randomized clinical assay between ciprofloxacin, norfloxacin and chloramphenicol as antibiotic prophylaxis in prostate biopsy. Two hundred and fifty-seven patients were randomized in 4 groups: 1) single dose of ciprofloxacin 2 hours before the procedure; 2) ciprofloxacin 3 days; 3) chloramphenicol 3 days; and 4) norfloxacin 3 days. The schemes using ciprofloxacin presented better results in prophylaxis previously to prostate biopsy. The single dose of ciprofloxacin is recommended due to its posologic ease and low cost, associated with a therapeutic response equivalent to a 3-day regimen. Doctors Paschoalin and colleagues from Ribeirão Preto School of Medicine, São Paulo, Brazil, investigated on page 300 the prevalence of prostate carcinoma in a sample of volunteers known to have a large proportion of Bantu African ancestors, and the performance of total PSA (tPSA), PSA density (PSAD) and free-to-total PSA ratio (f/tPSA) on the diagnosis. The authors found that tumor prevalence was higher in Non-White than in White phenotype. Also, they proposed that the association of tPSA at a cut-off level of 2.5 ng/ml with a PSAD of 0.08 or a f/tPSA of 20% for biopsy indication deserves further investigations as an alternative to tPSA cut-off level of 4 ng/ml. Doctor Barros and associates, from Federal University of Bahia, Brazil, analyzed on page 306 the prevalence of prostate adenocarcinoma according to race in an university hospital. The authors studied 580 patients with mean age of 60.7 ± 10.0 years, with 116 Whites (20.0%), 276 Mulattos (47.6%) and 188 Blacks (32.4%). Prostate adenocarcinoma was found in 16.6% of patients aged between 40 and 79 years. The authors did not find statistically significant influence of race in the population with prostate adenocarcinoma. Dr. Gustavo F. Carvalhal, from Catholic University, Rio Grande do Sul, Brazil, provided an interesting editorial comment on racial implications in prostate cancer Dr. Francisco J.B. Sampaio Editor-in-Chief 290 Clinical Urology RADICAL PERINEAL PROSTATECTOMY International Braz J Urol Vol. 29 (4): 291-299, July - August, 2003 Official Journal of the Brazilian Society of Urology CASE SELECTION AND OUTCOME OF RADICAL PERINEAL PROSTATECTOMY IN LOCALIZED PROSTATE CANCER JEFFREY M. HOLZBEIERLEIN (1), PETER LANGENSTROER (2), H.J. PORTER II (1), J. BRANTLEY THRASHER (1) Section of Urology, University of Kansas Medical Center (1), Kansas City, Kansas,USA, and Division of Urology, Medical College of Wisconsin (2), Milwaukee, Wisconsin, USA ABSTRACT Radical prostatectomy continues to play a central role in the management of localized pros- tate cancer. The majority of patients diagnosed with prostate cancer will undergo radical prostatec- tomy. A decrease in the morbidity of this surgical procedure has been accomplished through an im- proved understanding of pelvic anatomy and a greater understanding of the natural history of prostate cancer. Recently, minimally invasive techniques have been applied to radical prostatectomy (laparoscopic prostatectomy) in order to further decrease the morbidity of this operation. What re- mains to be determined is whether this approach confers the same long term surgical outcomes as the open approach. One method which offers known long term outcomes coupled with decreased morbid- ity is the radical perineal prostatectomy. The purpose of this paper is to review the criteria for patient selection as well as outcomes of the radical perineal prostatectomy. Key words: prostatic neoplasms; prostatectomy; perineal; outcomes; surgical technique Int Braz J Urol. 2003; 29: 291-9 INTRODUCTION removal of prostatic carcinoma. In 1866, Kuchler was the first to suggest that the entire prostate could be Perineal prostatectomy is the oldest means removed using this approach, but it was Billroth, in of prostate resection and has its origins from the 1867, who first described the perineal prostatectomy perineal lithotomy which was first described in 400 for the treatment of prostate cancer in a professional BC (1). In 25 AD, Celsus developed a curved perineal journal (3). incision which would eventually become the basis In 1901, Dr. Hugh Hampton Young employed for the incision used in the perineal prostatectomy the curved perineal incision to perform a prostatec- today (1). Covillard is credited with performing the tomy for the removal of the entire prostate for benign first removal of a portion of the prostate during re- prostatic hyperplasia (1). Dr. Young stressed the im- moval of a bladder stone through the perineum in portance of performing all portions of the procedure 1639, although he and other surgeons, at the time, under direct visualization and developed such tools used a median incision in the perineum rather than as the Young retractor and the perineal table to facili- the curved incision described by Celsus (2). Through- tate visualization (Figures-1, 2 and 3). While remov- out the 18th and 19th centuries, several surgeons re- ing the prostate for benign disease, Dr. Young noted ported the removal of portions of the prostate similar that some of the prostates were involved with cancer. to Covillard; however, the first planned prostate He then performed a series of autopsies in men with enucleation through a median perineal incision was prostate carcinoma to identify the pattern of spread performed by Guthrie in 1834 (2). This subsequently of the cancer. This led him to believe that prostate led to the use of the median perineal incision for the cancer spread along the ampullae of the vasa to the 291 RADICAL PERINEAL PROSTATECTOMY Figure 1 – Dr. Young’s original depiction of prostatic tractor used for enucelation of the hypertrophied lobes of the prostate Figure 2 – The Young retractor which is still used today for the perineal prostatectomy. Figure 3 – The Young perineal table 292 RADICAL PERINEAL PROSTATECTOMY seminal vesicles, and that the cancer was usually con- 1960’s and early 1970’s, literature began to accumu- tained within Denovillier’s fascia (4). During this late on the morbidity associated with radiation, but it same time period, Dr. Halsted was performing the continued to play a significant role in the treatment radical mastectomy for the treatment of breast can- of prostate cancer due to the significant morbidity, cer. Together they developed a radical operation to especially blood loss, associated with radical pros- remove the prostate, the fascia of Denovillier, the tatectomy. Finally, in 1979 Reiner & Walsh reported seminal vesicles, ampullae of the vasa, and the vesi- early meticulous ligation