eMedicine Specialties > Urology > Cancer, Prostate

Prostate Cancer - Radical Retropubic Prostatectomy: Workup

Author: Reza Ghavamian, MD, Director, Associate Professor, Department of Urology, Section of Urologic Oncology, Montefiore Medical Center, Albert Einstein College of Medicine
Coauthor(s): Horst Zincke, MD, PhD, Professor, Department of Urology, Mayo Medical School
Contributor Information and Disclosures

Updated: Apr 27, 2009

Workup

Laboratory Studies

  • Routine preoperative laboratory studies are performed. These include CBC count, blood chemistry (CHEM 7), and urinalysis.
  • The patient's blood also is typed and screened. The authors do not routinely advocate autologous blood donation because they do not find this cost-effective. In this setting, the surgeon's individual technique and average blood loss advocates the recommendation. Certainly, if the patient adamantly requests autologous blood donation, the authors usually comply.

Imaging Studies

  • Electrocardiography and chest radiography: These studies are performed.
  • Radionuclide bone scan
    • Prostate cancer tends to metastasize to bone; thus, many physicians once routinely performed a bone scan for the detection of metastases in localized prostate cancer. However, careful review of the literature since the advent of PSA reveals that a bone scan is not always necessary.
    • A study from the Mayo Clinic addressed this issue, and serum PSA testing was found to be the most accurate clinical parameter in evaluating whether a bone scan finding is likely to be positive.6 In 306 patients with a serum PSA level of less than 20 ng/mL, only 1 patient was found to have skeletal metastases. Among 209 patients with a PSA level of less than 10 ng/mL, none had metastases. This yields a negative predictive value of 100% for patients with a PSA level of less than 10 ng/mL and 99.7% for patients with a PSA level of less than 20 ng/mL. These results have been validated by other institutions.
    • The authors perform a bone scan in patients with a serum PSA level of greater than 20 ng/mL. This modality is also is justified in patients with a biopsy Gleason score of 7 who have and a PSA level of greater than 10 ng/mL. The authors also perform a bone scan in patients with high Gleason scores (8-10) because the serum PSA level in these patients may not accurately reflect disease burden.
  • CT scanning and MRI
    • Both of these modalities are used to assess nodal size to detect possible nodal metastases. CT scanning is not accurate in the detection of nodal disease; the sensitivity ranges from 33-50%, but even these sensitivities are limited to series in which patients had locally advanced disease. Currently, CT scan has a very low yield in the detection of metastases for the average patient with localized prostate cancer who presents to the office.
    • In a 1995 study, CT scan findings were positive in only 13 of 861 patients (1.5%), all with a PSA level of greater than 20 ng/mL.7 During surgical staging of 409 patients with normal CT scan results, 15 were found to have nodal metastases, 13 of which were microscopic. Therefore, CT scanning would not have changed the ultimate management and is not an essential component of staging clinically localized prostate cancer in low-risk patients. Risk in cases of prostate cancer and the possibility of locally advanced disease or nodal metastases can be predicted reliably with validated prostate-cancer nomogram data. The probability of positive lymph nodes is estimated using local clinical stage, primary Gleason grade, and serum PSA concentration. These nomograms can be used to identify high-risk patients, in whom CT scanning might be justified.
    • Pelvic MRI also yields low sensitivity: 20-30%, at best, in the detection of nodal metastases. The decision to perform pelvic MRI in patients with prostate cancer should be based on the same rationale used in deciding whether to perform CT scanning (ie, calculating the risk based on other clinical variables and selecting the appropriate patients).
  • Prostascint scan
    • Monoclonal antibody technology has had a recent application in prostate-cancer staging. The CYT-356 antibody (Cytogen Corporation) recognizes an epitope of the prostate-specific membrane (PSM) antigen and can be useful for evaluation of nodal and distant metastases in prostate cancer. The overall sensitivity is 50-60%. This modality can be used to detect recurrence in previously treated patients or to stage patients with poor prognostic parameters (high Gleason grade and PSA level, with negative results on bone scan and CT scanning) prior to definitive local therapy. One area of clinical utility may be to detect lymph node metastases before radical prostatectomy. Studies in this area have revealed the sensitivity and specificity to be approximately 60% and 70%, respectively. Positive and negative predictive values have been approximately 60% and 70%, respectively.
    • These values, although superior to those of CT scanning in the evaluation of lymph nodes, are not accurate enough to justify the routine use of this modality. Many clinicians perform CT scanning in the poor-risk patient (Gleason grade ³ 7 and/or PSA level >20 ng/mL), mostly to rule out bulky obvious nodal disease. In the absence of such findings, many argue that lymph node dissection is mandatory and unavoidable and that a Prostascint scan does not provide an added benefit.
    • Prostascint scanning is also used to detect recurrent disease in the prostatic fossa in patients who have undergone prostatectomy. Kahn et al (1994) reviewed the relationship between prostatic fossa biopsies and scan results and found that the sensitivity of Prostascint scanning in this setting was 49%, the specificity was 70%, the positive predictive value was 50%, and the negative predictive value was 70%.8 In deciding whether to institute salvage radiotherapy, other factors, such as Gleason score, onset, and the slope of the postoperative rise in PSA level, are important. These factors, in association with the above results, indicate that a Prostascint scan is not always crucial for clinical decision-making in this setting.
    • Considerable expertise is required for proper interpretation of the Prostascint scan, contributing to the suboptimal value of the scans.
  • Positron emission tomography (PET): The use of PET scanning in prostate cancer is debatable. Prostate cancer is not an active metabolic malignancy, and the uptake of 18-fluorodeoxyglucose (FDG) may be suboptimal. Data currently do not support an additional role for PET in the staging and evaluation of de novo or recurrent prostate cancer.

More on Prostate Cancer - Radical Retropubic Prostatectomy

Overview: Prostate Cancer - Radical Retropubic Prostatectomy
Workup: Prostate Cancer - Radical Retropubic Prostatectomy
Treatment: Prostate Cancer - Radical Retropubic Prostatectomy
Follow-up: Prostate Cancer - Radical Retropubic Prostatectomy
Multimedia: Prostate Cancer - Radical Retropubic Prostatectomy
References
Further Reading
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References

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Further Reading

For additional information, see Medscape’s Prostate Cancer Resource Center.

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Keywords

radical retropubic prostatectomy, RRP, robotic-assisted laparoscopic radical prostatectomy, RALP, prostate cancer, prostate-specific antigen, PSA, adenocarcinoma of the prostate, perineal prostatectomy, urinary incontinence, impotence, erectile dysfunction, prostatic adenocarcinoma, prostate adenocarcinoma, radical prostatectomy, minimally invasive radical prostatectomy, robotic prostatectomy, laparoscopic radical prostatectomy

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Contributor Information and Disclosures

Author

Reza Ghavamian, MD, Director, Associate Professor, Department of Urology, Section of Urologic Oncology, Montefiore Medical Center, Albert Einstein College of Medicine
Reza Ghavamian, MD is a member of the following medical societies: American Urological Association and Society of Urologic Oncology
Disclosure: Nothing to disclose.

Coauthor(s)

Horst Zincke, MD, PhD, Professor, Department of Urology, Mayo Medical School
Horst Zincke, MD, PhD is a member of the following medical societies: American Medical Association, Minnesota Medical Association, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Dan Theodorescu, MD, PhD, Paul Mellon Professor of Urologic Oncology, Department of Urology, University of Virginia Health Sciences Center
Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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