No description available.

Background: We evaluated the validity of a set of 11 quality indicators for prostate cancer radiotherapy and radical prostatectomy by examining their association with outcomes. The selected indicators were: hospital volume, pre-treatment risk assessment, patient consultation with a radiation oncologist, appropriate follow-up care, leg immobilization during radiotherapy, bladder filling during radiotherapy, portal film target localization, use of nerve sparing surgery, operative blood loss, margin status and pelvic lymph node dissection. The selected outcomes were: cause-specific survival, disease-free survival, late morbidity (urinary incontinence, gastrointestinal and genitourinary morbidity), change in node stage from clinical N0 to pathologic N1, and margin status. Methods: Our study sample consisted of 1570 prostate cancer patients who were diagnosed in Ontario between January 1, 1990 and December 31, 1998 who received radical prostatectomy within 6 months of diagnosis (n=646), or curative radiotherapy within 9 months of diagnosis (n=924). Quality of care, outcomes, and potential confounders were measured using patient chart and administrative data. Regression techniques were used to evaluate the associations between quality indicators and relevant outcomes. Results: For patients treated surgically, hospital volume met our test of validity. Patients treated in the lowest volume hospital (0-1 RP/month) were at greater risk of prostate cancer death than patients treated in the highest volume hospitals (7+ RP/month) (HR=5.37 95% CI=1.23-23.46). For patients treated with radiotherapy, leg immobilization and bladder filling during radiotherapy met our test of validity. Patients treated without leg immobilization were more likely to experience urinary incontinence (RR=2.18, 95% CI=1.23-3.87) and genitourinary late morbidities (RR=1.72, 95% CI=1.16-2.56) than patients who received leg immobilization. Patients who were treated with an empty bladder were more likely to experience GU late morbidities (RR=1.98, 95% CI=1.08-3.63) than those treated with a full bladder. The remaining indicators did not meet our test of validity. Conclusion: Our results support the validity of one surgical quality indicator and two radiotherapy quality indicators. Explanations for our non-significant findings, including limited study power, data quality, our definition and measurement of indicators, and a true failure to predict outcome(s) are discussed, and recommendations for further research are presented. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2011-09-07 20:26:34.461

Objetivo: Analisar a casuística de prostatovesiculectomias radicais com linfadenectomia ilíaca avaliando a validade das Tabelas de Partin versão 2001. Estudar variáveis que possam interferir no confinamento ou não da neoplasia como retardo cirúrgico, peso prostático, resultados referentes à biópsia e ano da cirurgia. Material e Métodos: Avaliação retrospectiva de 568 prontuários de pacientes submetidos à cirurgia para câncer de próstata clinicamente localizado entre 1995 até agosto de 2005 no Hospital de Clínicas de Porto Alegre. Foram excluidos quem tivesse feito hormonioterapia neoadjuvante ou com diagnóstico feito por ressecção endoscópica da próstata e aqueles com insuficiência dos dados no prontuário. Estágio clínico pelo toque retal , valores de PSA e dados da biópsia que diagnosticou a neoplasia, assim como dos dados da peça da prostatectomia radical foram coletados. Os valores preditivos das Tabelas de Partin, versão 2001 foram comparados com os do espécime cirúrgico e analisados através de Curvas R.OC. Foram também avaliados tempo de espera para cirurgia, peso da próstata, ano da cirurgia, uni ou bilateralidade tumoral na biópsia e qual a biópsia que diagnosticou (primeira ou ulterior) e analisados como fatores preditivos para confinamento ou não da neoplasia. Resultados: A idade média do pacientes foi 63 (42-77). A percentagem de estágio T1c foi de 63 %. Pacientes com escore de Gleason 2-4 na biópsia constituiram 20,2 %, notadamente antes de 2000. O percentual de pacientes com níveis de PSA menores de 4,0 ng/ml foi de 8,3 % e acima de 10,0 ng/ml foi de 35 %. Os percentuais de doença confinada ao órgão, extensão extra-prostática, invasão de vesículas seminais e metástases linfonodais foram 48,2 %, 35,3%, 13,9% e 2,6% , respectivamente. A área sob a curva calculada para doença confinada ao órgão foi de 0,65 , enquanto as áreas sob as curvas para extensão extra-prostática, invasão de vesículas seminais e metástases linfonodais foi respectivamente 0,54; 063 e 0,77. Pacientes que tiveram o diagnóstico já na primeira biópsia, ou com biópsias bilateralmente comprometidas e aqueles operados antes de 2000 tinham tendência ao não confinamento. Biópsias realizadas a partir de 2000 que já foram positivas na primeira tentativa tiveram maior tendência ao confinamento do que até 1999. Conclusão: As Tabelas de Partin tiveram valor preditivo marginal para as características patológicas finais como doença confinada ao órgão e invasão de vesículas seminais e valor preditivo importante para metástases linfonodais. Não mostraram valor preditivo para extensão extra-prostática. Bilateralidade tumoral na biópsia, diagnóstico na primeira biópsia (especialmente até 1999) e cirurgia antes de 2000 configuraram situações com tendência a tumores não confinados. / Objective: The predictive value of current Partin tables (2001) has been not validated in most of the countries as well Brazil. Therefore, we evaluated the validity of 2001 Partin tables for the ability to predict the pathological stage in specimens of radical prostatectomy. Also, we analysed how biopsies can predict results for organ confinement or not and as well what the year of the surgery can make in organ confinement issue . Materials and methods: The clinical and pathological findings of 568 patients who have had radical prostatectomy and iliac lymphadenectomy from 1995 to 2005 at Hospital de Clínicas de Porto Alegre were assessed. Those with missing information, patients who had neoadjuvant endocrine treatment and those who had the diagnosis by transurethral ressection of prostate were excluded. Serum PSA, clinical stage, biopsy characteristics and the pathological features of the specimens were collected. The predictive value of Partin tables and pathological findings of prostatectomy specimens were compared and analyzed according to Receiver Operating Characteristics curves. The delay of the surgery, prostate weight, year of the surgery, bilaterality of the biopsies and if the diagnostic biopsy was the first or not were important for the organ confined disease were also tested. Results: Median age of the patients was 63(42-77). The percentage of patients with clinical stage T1c was 63%. Gleason score 2-4 in biopsy constituted 20,2 %, at mainly before 2000. The ratio of patients with serum PSA above 4,0 ng/ml was 8,3% and higher than 10,0 ng/ml was 35%.Organ confined disease, extra-prostatic extension, seminal vesicle involvement and lymph node metastasis were 48,2%; 35,3%; 13,9 % and 2,6% respectively. Area under curve (AUC) values for organ confined disease, extra-prostatic extension, seminal vesicle invasion and lymph node involvement were 0,65 ; 0,54; 0,63 and 0,77. Tumor bilaterallity at biopsy and positive biopsy at the first procedure (at least until 1999) as well radical prostatectomy before 2000 were predictors for non organ confined prostate cancer. Conclusion: Partin tables have a marginally predictive value for the pathological features like organ confined disease and seminal vesicle involvement and a good predictive value for lymph node metastasis prediction. They don’t have predictive value for extra-prostatic extension. Positive first biopsy, bilateral tumor at biopsy and radical prostatectomy before 2000 were predictive for non organ confined disease.

Objetivo: Analisar a casuística de prostatovesiculectomias radicais com linfadenectomia ilíaca avaliando a validade das Tabelas de Partin versão 2001. Estudar variáveis que possam interferir no confinamento ou não da neoplasia como retardo cirúrgico, peso prostático, resultados referentes à biópsia e ano da cirurgia. Material e Métodos: Avaliação retrospectiva de 568 prontuários de pacientes submetidos à cirurgia para câncer de próstata clinicamente localizado entre 1995 até agosto de 2005 no Hospital de Clínicas de Porto Alegre. Foram excluidos quem tivesse feito hormonioterapia neoadjuvante ou com diagnóstico feito por ressecção endoscópica da próstata e aqueles com insuficiência dos dados no prontuário. Estágio clínico pelo toque retal , valores de PSA e dados da biópsia que diagnosticou a neoplasia, assim como dos dados da peça da prostatectomia radical foram coletados. Os valores preditivos das Tabelas de Partin, versão 2001 foram comparados com os do espécime cirúrgico e analisados através de Curvas R.OC. Foram também avaliados tempo de espera para cirurgia, peso da próstata, ano da cirurgia, uni ou bilateralidade tumoral na biópsia e qual a biópsia que diagnosticou (primeira ou ulterior) e analisados como fatores preditivos para confinamento ou não da neoplasia. Resultados: A idade média do pacientes foi 63 (42-77). A percentagem de estágio T1c foi de 63 %. Pacientes com escore de Gleason 2-4 na biópsia constituiram 20,2 %, notadamente antes de 2000. O percentual de pacientes com níveis de PSA menores de 4,0 ng/ml foi de 8,3 % e acima de 10,0 ng/ml foi de 35 %. Os percentuais de doença confinada ao órgão, extensão extra-prostática, invasão de vesículas seminais e metástases linfonodais foram 48,2 %, 35,3%, 13,9% e 2,6% , respectivamente. A área sob a curva calculada para doença confinada ao órgão foi de 0,65 , enquanto as áreas sob as curvas para extensão extra-prostática, invasão de vesículas seminais e metástases linfonodais foi respectivamente 0,54; 063 e 0,77. Pacientes que tiveram o diagnóstico já na primeira biópsia, ou com biópsias bilateralmente comprometidas e aqueles operados antes de 2000 tinham tendência ao não confinamento. Biópsias realizadas a partir de 2000 que já foram positivas na primeira tentativa tiveram maior tendência ao confinamento do que até 1999. Conclusão: As Tabelas de Partin tiveram valor preditivo marginal para as características patológicas finais como doença confinada ao órgão e invasão de vesículas seminais e valor preditivo importante para metástases linfonodais. Não mostraram valor preditivo para extensão extra-prostática. Bilateralidade tumoral na biópsia, diagnóstico na primeira biópsia (especialmente até 1999) e cirurgia antes de 2000 configuraram situações com tendência a tumores não confinados. / Objective: The predictive value of current Partin tables (2001) has been not validated in most of the countries as well Brazil. Therefore, we evaluated the validity of 2001 Partin tables for the ability to predict the pathological stage in specimens of radical prostatectomy. Also, we analysed how biopsies can predict results for organ confinement or not and as well what the year of the surgery can make in organ confinement issue . Materials and methods: The clinical and pathological findings of 568 patients who have had radical prostatectomy and iliac lymphadenectomy from 1995 to 2005 at Hospital de Clínicas de Porto Alegre were assessed. Those with missing information, patients who had neoadjuvant endocrine treatment and those who had the diagnosis by transurethral ressection of prostate were excluded. Serum PSA, clinical stage, biopsy characteristics and the pathological features of the specimens were collected. The predictive value of Partin tables and pathological findings of prostatectomy specimens were compared and analyzed according to Receiver Operating Characteristics curves. The delay of the surgery, prostate weight, year of the surgery, bilaterality of the biopsies and if the diagnostic biopsy was the first or not were important for the organ confined disease were also tested. Results: Median age of the patients was 63(42-77). The percentage of patients with clinical stage T1c was 63%. Gleason score 2-4 in biopsy constituted 20,2 %, at mainly before 2000. The ratio of patients with serum PSA above 4,0 ng/ml was 8,3% and higher than 10,0 ng/ml was 35%.Organ confined disease, extra-prostatic extension, seminal vesicle involvement and lymph node metastasis were 48,2%; 35,3%; 13,9 % and 2,6% respectively. Area under curve (AUC) values for organ confined disease, extra-prostatic extension, seminal vesicle invasion and lymph node involvement were 0,65 ; 0,54; 0,63 and 0,77. Tumor bilaterallity at biopsy and positive biopsy at the first procedure (at least until 1999) as well radical prostatectomy before 2000 were predictors for non organ confined prostate cancer. Conclusion: Partin tables have a marginally predictive value for the pathological features like organ confined disease and seminal vesicle involvement and a good predictive value for lymph node metastasis prediction. They don’t have predictive value for extra-prostatic extension. Positive first biopsy, bilateral tumor at biopsy and radical prostatectomy before 2000 were predictive for non organ confined disease.

Objetivo: Analisar a casuística de prostatovesiculectomias radicais com linfadenectomia ilíaca avaliando a validade das Tabelas de Partin versão 2001. Estudar variáveis que possam interferir no confinamento ou não da neoplasia como retardo cirúrgico, peso prostático, resultados referentes à biópsia e ano da cirurgia. Material e Métodos: Avaliação retrospectiva de 568 prontuários de pacientes submetidos à cirurgia para câncer de próstata clinicamente localizado entre 1995 até agosto de 2005 no Hospital de Clínicas de Porto Alegre. Foram excluidos quem tivesse feito hormonioterapia neoadjuvante ou com diagnóstico feito por ressecção endoscópica da próstata e aqueles com insuficiência dos dados no prontuário. Estágio clínico pelo toque retal , valores de PSA e dados da biópsia que diagnosticou a neoplasia, assim como dos dados da peça da prostatectomia radical foram coletados. Os valores preditivos das Tabelas de Partin, versão 2001 foram comparados com os do espécime cirúrgico e analisados através de Curvas R.OC. Foram também avaliados tempo de espera para cirurgia, peso da próstata, ano da cirurgia, uni ou bilateralidade tumoral na biópsia e qual a biópsia que diagnosticou (primeira ou ulterior) e analisados como fatores preditivos para confinamento ou não da neoplasia. Resultados: A idade média do pacientes foi 63 (42-77). A percentagem de estágio T1c foi de 63 %. Pacientes com escore de Gleason 2-4 na biópsia constituiram 20,2 %, notadamente antes de 2000. O percentual de pacientes com níveis de PSA menores de 4,0 ng/ml foi de 8,3 % e acima de 10,0 ng/ml foi de 35 %. Os percentuais de doença confinada ao órgão, extensão extra-prostática, invasão de vesículas seminais e metástases linfonodais foram 48,2 %, 35,3%, 13,9% e 2,6% , respectivamente. A área sob a curva calculada para doença confinada ao órgão foi de 0,65 , enquanto as áreas sob as curvas para extensão extra-prostática, invasão de vesículas seminais e metástases linfonodais foi respectivamente 0,54; 063 e 0,77. Pacientes que tiveram o diagnóstico já na primeira biópsia, ou com biópsias bilateralmente comprometidas e aqueles operados antes de 2000 tinham tendência ao não confinamento. Biópsias realizadas a partir de 2000 que já foram positivas na primeira tentativa tiveram maior tendência ao confinamento do que até 1999. Conclusão: As Tabelas de Partin tiveram valor preditivo marginal para as características patológicas finais como doença confinada ao órgão e invasão de vesículas seminais e valor preditivo importante para metástases linfonodais. Não mostraram valor preditivo para extensão extra-prostática. Bilateralidade tumoral na biópsia, diagnóstico na primeira biópsia (especialmente até 1999) e cirurgia antes de 2000 configuraram situações com tendência a tumores não confinados. / Objective: The predictive value of current Partin tables (2001) has been not validated in most of the countries as well Brazil. Therefore, we evaluated the validity of 2001 Partin tables for the ability to predict the pathological stage in specimens of radical prostatectomy. Also, we analysed how biopsies can predict results for organ confinement or not and as well what the year of the surgery can make in organ confinement issue . Materials and methods: The clinical and pathological findings of 568 patients who have had radical prostatectomy and iliac lymphadenectomy from 1995 to 2005 at Hospital de Clínicas de Porto Alegre were assessed. Those with missing information, patients who had neoadjuvant endocrine treatment and those who had the diagnosis by transurethral ressection of prostate were excluded. Serum PSA, clinical stage, biopsy characteristics and the pathological features of the specimens were collected. The predictive value of Partin tables and pathological findings of prostatectomy specimens were compared and analyzed according to Receiver Operating Characteristics curves. The delay of the surgery, prostate weight, year of the surgery, bilaterality of the biopsies and if the diagnostic biopsy was the first or not were important for the organ confined disease were also tested. Results: Median age of the patients was 63(42-77). The percentage of patients with clinical stage T1c was 63%. Gleason score 2-4 in biopsy constituted 20,2 %, at mainly before 2000. The ratio of patients with serum PSA above 4,0 ng/ml was 8,3% and higher than 10,0 ng/ml was 35%.Organ confined disease, extra-prostatic extension, seminal vesicle involvement and lymph node metastasis were 48,2%; 35,3%; 13,9 % and 2,6% respectively. Area under curve (AUC) values for organ confined disease, extra-prostatic extension, seminal vesicle invasion and lymph node involvement were 0,65 ; 0,54; 0,63 and 0,77. Tumor bilaterallity at biopsy and positive biopsy at the first procedure (at least until 1999) as well radical prostatectomy before 2000 were predictors for non organ confined prostate cancer. Conclusion: Partin tables have a marginally predictive value for the pathological features like organ confined disease and seminal vesicle involvement and a good predictive value for lymph node metastasis prediction. They don’t have predictive value for extra-prostatic extension. Positive first biopsy, bilateral tumor at biopsy and radical prostatectomy before 2000 were predictive for non organ confined disease.

Quality-of-life and functional outcomes are important in the choice of treatment for men with localized prostate cancer. These issues were investigated in the present thesis. All living 400 men randomized to radical prostatectomy or watchful waiting from 1989 to 1999 in the Scandinavian Prostate Cancer Group Number 4 (SPCG-4) were included. An additional 281 men compromised an age-matched control group. Physical symptoms, symptom-induced stress, sense of well-being and self-assessed quality of life were evaluated by a study-specific questionnaire. Results showed that prostate cancer men, regardless if they were allocated to radical prostatectomy or watchful waiting were suffering of long term adverse effects, mainly erectile dysfunction, urinary leakage and voiding symptoms. In the prostatectomy group, erectile dysfunction and urinary leakage were often consequences of surgery; in the watchful waiting group the side-effects could be caused by tumor progression. The quality of life deteriorated over time. High self-assessed quality of life was reported by 35 % in the radical, 34 % in watchful-waiting, and 43 % in the control groups after a median follow-up time of 12.2 years. The SPCG-4 men significantly more often reported anxiety than did controls. Erectile dysfunction was associated with the most negative influence on quality of life in both SPCG-4 groups. Men in the prostatectomy group were more distressed by erectile dysfunction than watchful waiting. Androgen deprivation therapy had negative effects on all psychological parameters, including quality of life, for the watchful waiting but not for the prostatectomy group. Information about the prostate-cancer disease was significantly higher in the radical-prostatectomy group than in watchful waiting. Check-ups were associated with worry, especially for those on androgen deprivation therapy. Open radical prostatectomy led to an increased rate of inguinal hernia compared with robot-assisted technique. In conclusion, the data of this thesis emphasize that it takes more than a decade to understand the patterns of adverse effects and time dimension of their occurrence for each treatment. Consideration of quality of life has a high priority to aid the ageing man through the shifting scenarios of localized prostate cancer.

Background: To explore cross‐sectional and longitudinal differences in general health‐related and prostate cancer‐specific quality of life (QoL) after robotic‐assisted (RARP) and laparoscopic (LRP) radical prostatectomy and to analyze predictive variables for QoL outcomes. Methods: In this multicenter, randomized controlled trial, prostate cancer patients were randomly assigned 3:1 to undergo either RARP or LRP. Patient‐reported outcomes were prospectively collected before and 1, 3, 6, 12 months after radical prostatectomy and included QoL as a secondary outcome. Validated questionnaires were used to assess general health‐related (EORTC QLQ‐C30) and prostate cancerspecific (QLQ‐PR25) QoL. Cross‐sectional and longitudinal contrasts were analyzed through linear mixed models. Predictive variables for QoL outcomes were identified by general linear modeling. Results: Of 782 randomized patients, QoL was evaluable in 681 patients. In terms of general QoL, the cross‐sectional analysis showed only small differences between study arms, whereas longitudinal comparison indicated an advantage of RARP on recovery: RARP patients reported an earlier return to baseline in global health status (3 vs. 6 months) and social functioning (6 vs. 12 months). In role functioning, only the RARP arm regained baseline scores. Regarding prostate‐specific QoL, LRP patients experienced more urinary symptoms and reported 3.2 points (95% confidence interval 0.4–6, p = 0.024) higher mean scores at 1‐month follow‐up and in mean 2.9 points (0.1–5, p = 0.042) higher urinary symptoms scores at 3‐month follow‐up than RARP patients. There were no other significant differences between treatment groups. Urinary symptoms, sexual activity, and sexual function remained significantly worse compared with baseline at all time points in both arms. Conclusions: Compared with LRP, the robotic approach led to an earlier return to baseline in several domains of general health‐related QoL and better short‐term recovery of urinary symptoms. Predictive variables such as the scale‐specific baseline status and bilateral nerve‐sparing were confirmed.:1 Abkürzungsverzeichnis 3 2 Einführung 4 2.1 Das Prostatakarzinom 4 2.1.1 Vorsorge und Diagnostik 4 2.1.2 Grundsätze der Therapie 5 2.1.3 Die radikale Prostatektomie 6 2.2 Lebensqualität 8 2.2.1 Gesundheitsbezogene Lebensqualität 8 2.2.2 Lebensqualität von Prostatakarzinompatienten 9 2.2.3 Prädiktoren der Lebensqualität nach radikaler Prostatektomie 12 2.3 Die LAP-01 Studie 13 2.3.1 Studiendesign 13 2.3.2 Lebensqualität im Rahmen der LAP-01 Studie 15 2.4 Zielsetzung und Fragestellung 16 3 Publikationsmanuskript 17 4 Zusammenfassung der Arbeit 28 5 Literaturverzeichnis 33 6 Anlagen 39 6.1 EORTC QLQ-C30 39 6.2 EORTC QLQ-PR25 42 7 Darstellung des eigenen Beitrags 44 8 Selbstständigkeitserklärung 45 9 Lebenslauf 46 10 Danksagung 48

BAKGRUND: Prostatacancer (PCa) är den vanligaste cancerformen bland män i Sverige. Efter kirurgisk behandling, radikal prostatektomi (RP), drabbas många av urininkontinens och sexuella besvär. Studier på kvinnor visar att urininkontinens påverkar sexuell lust men det finns få liknande studier bland män. SYFTE: Syftet med studien är att jämföra självskattad sexuell lust bland män med och utan inkontinens, ett år efter RP. METOD: Denna kvantitativa tvärsnittstudie utgår från enkätmaterial insamlat i en pågående prospektiv studie. Data insamlat bland 1751 män, ett år efter RP, har analyserats och jämförts mellan två grupper (fall-kontrollstudie). RESULTAT: Resultatet visar att män med urininkontinens skattar lägre sexuell lust, ett år efter RP, än män utan urininkontinens samt att de i högre grad beskriver tanken på ett fortsatt liv med sina sexualproblem med negativa begrepp. KONKLUSION: Män som genomgått RP, och i synnerhet de som har urininkontinens, har nedsättningar i sexuallivet. Sjuksköterskan bör uppmärksamma och ge tid till samtal om påverkan på sexuallivet efter RP, med både patient och partner. Ökad kunskap inom området bidrar till ökad förståelse, och behövs för att sjuksköterskor ska kunna hjälpa dessa patienter. Nedsatt sexuell lust hos män är ett outforskat område och vidare forskning behövs. / BACKGROUND: Prostate cancer (PCa) is the most common form of cancer among Swedish men. Urinary incontinence and sexual dysfunction are two side effects that many men experience after surgery, radical prostatectomy (RP). Previous studies show that urinary incontinence has negative effects on women’s sexual desire. Few similar studies concern men. AIM: The aim of the study is to compare self-reported sexual desire among men with and without urinary incontinence, one year post-surgical treatment (RP). METHOD: This quantitative, cross-sectional study is based on a self-reported survey from an ongoing prospective study. Data collected from 1751 men, one year post-treatment, have been analyzed and compared between two groups (case-control study). RESULT: The result shows that men with urinary incontinence after RP have less sexual desire than men without urinary incontinence. These men are also less satisfied with the idea of spending the rest of their lives with their sexual problems. CONCLUSION: Men that have undergone RP, especially the ones who have urinary incontinence, experience sexual dysfunction. Nurses need to acknowledge and initiate dialogues with patients and their partners about effects on sexual life after RP. Research concerning men’s sexual desire will help nurses’ knowledge and ability to discuss sexual problems. More studies about men’s reduced sexual desire are necessary.

Background Screening for prostate cancer is debated, there is conflicting data on the net benefit of screening. Men who consider screening need to be informed on the pros and cons. Rehospitalization after surgery can be used as an indicator of general quality of care. For radical prostatectomy, little is known on the readmission rate after surgery. Men diagnosed with low- and intermediate-risk prostate cancer have low prostate-cancer specific mortality. However, adverse effects after curative treatment can be severe and decrease quality of life. Curative treatments for prostate cancer differ mainly in the pattern of adverse effects but detailed analysis of long-term adverse effects is lacking. The aim of this thesis was to assess the perioperative quality of radical prostatectomy and the risk of adverse effects after curative treatment for prostate cancer. Material and Methods In this thesis, data from the National Prostate Cancer Register (NPCR) and other nationwide Swedish registers were used. By use of the Swedish personal identity number, NPCR was cross-linked to other registers creating Prostate Cancer data Base Sweden (PCBaSe), a large dataset for research. Results The proportion of men who had received information on the pros and cons of screening for prostate cancer with PSA testing was low (14%) indicating that the majority of men who were screened did not make an informed decision. The risk of rehospitalization within 90 days after radical prostatectomy was approximately 10% and similar after retropubic and robot-assisted radical prostatectomy. Compared to controls, there was an increased risk of adverse effects after both radiotherapy and radical prostatectomy up to twelve years after treatment and the overall risk was quite similar after retropubic and robot-assisted radical prostatectomy. Conclusion Improved information to men on the pros and cons of PSA screening is warranted. The risk of adverse effects was elevated up to 12 years after curative treatment for prostate cancer. The pattern of adverse effects was different after radiotherapy and radical prostatectomy but quite similar after retropubic and robot-assisted radical prostatectomy.

Introdução: A curva de aprendizado em prostatectomia radical laparoscópica (PRL) pode variar de 10 a 150 procedimentos. Nesta fase, observa-se o maior número de complicações perioperatórias e conversões, além de resultados oncológicos e funcionais precários. Neste estudo, foram comparadas duas séries iniciais de PRL, realizadas pelos acessos transperitoneal (PRLT) e extraperitoneal (PRLE). Objetivos: Comparar os resultados obtidos com a realização da PRL pelos acessos transperitoneal e extraperitoneal durante a curva de aprendizado, avaliando-se os resultados perioperatórios, oncológicos e funcionais. Pacientes e métodos: Procedeuse a uma análise comparativa retrospectiva entre os dados das primeiras 40 PRLT realizadas no Hospital Getúlio Vargas de Pernambuco (grupo 1) e os dados das primeiras 40 PRLE realizadas no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (grupo 2). Resultados: Comparando-se as variáveis trans-operatórias dos grupos 1 e 2, observamos diferenças estatísticas na preservação dos feixes vásculonervosos (77,5% vs 90%; p=0,008), tempo cirúrgico total (175,0 min vs 267,6 min;p<0,001) e da perda sanguínea estimada (177,5 ml vs 292,4 ml; p<0,001). Duas complicações (5%) foram observadas no grupo 1 (sangramento e lesão retal) e quatro (10%) ocorreram no grupo 2 (sangramento-2, lesão retal e de bexiga). Conversão para procedimento aberto foi necessária em um caso em cada grupo (2,5%). No período pósoperatório, as principais diferenças estatisticamente significantes entre os grupos 1 e 2 foram observadas nas comparações do tempo de internamento, do tempo de uso de catéter uretral, no uso de opióides, na recorrência bioquímica, na taxa de continência urinária e no tempo médio de seguimento. Nenhuma diferença estatística foi observada na incidência de complicações precoces (17,5% vs 17,5%; p= 1,000), porém três complicações maiores foram observadas no grupo 1, levando ao óbito de um paciente neste grupo. Dentre as complicações pós-operatórias tardias, observou-se uma diferença estatística quando se comparou a taxa de complicações menores entre os grupos 1 e 2 (30% vs 15%; p=0,004). Na comparação dos resultados oncológicos entre os grupos 1 e 2, observou-se diferença estatística no número total de margens cirúrgicas positivas (MCP) (10,3% vs 32,5%; p=0,016) e no estadiamento patológico (pT2: 94,8% vs 70% e pT3: 5,2% vs 30%; p=0,005). Correlacionando-se o achado de MCP e estadiamento patológico, observou-se que a maioria das MCP no grupo 1 ocorreu no estadio pT2 (75%), ao passo que 77% das MCP no grupo 2 ocorreu no estadio pT3. Conclusões: O acesso transperitoneal mostrou-se mais eficiente que o acesso extraperitoneal para a realização da prostatectomia radical laparoscópica durante a curva de aprendizado, porém enfatizando que a taxa de complicações graves foi maior quando este acesso foi utilizado. / Introduction: The learning curve in laparoscopic radical prostatectomy (LRP) can vary from 10 to 150 procedures. This procedure can be done using the transperitoneal or the extraperitoneal approach. So far, there is no consensus about the best way to perform LRP, mainly during the initial phases of the LRP programs. Objectives: To analyze and compare the perioperative, oncological and functional results obtained with both approaches while performing LRP during the learning curve. Patients and Methods: Data of the first 40 transperitoneal LRP (Group 1) performed at Getúlio Vargas Hospital of Recife were compared with the first 40 extraperitoneal LRP (Group 2) performed at Clinics Hospital of State University of São Paulo. Results: On transoperative time, statistically significant difference were observed comparing groups 1 and 2 related to the preservation of the neurovascular bundles (77,5% x 90%; p=0,008), overall surgical time (175 min x 267,6 min; p<0,001) and estimated blood loss (177,5 ml x 292,4 ml; p<0,001). Two complications (5%) were observed in group 1 (bleeding and rectal injury), whereas four (10%) were seen in group 2 (bleeding- 5%, rectal and bladder injury). Open conversion occurred in one case (2,5%) in both groups. On postoperative time, statistical difference comparing the groups 1 and 2 were seen in the in-hospital time, indwelling catheter time, narcotic use, biochemical recurrence and mean follow-up time. No statistical difference was observed related to the incidence of early complications (17,5% vs 17,5%; p= 1,000), but three major complications occurred in group 1, leading to one death in this group. On late postoperative time, a statistical difference was observed in the incidence of minor complications (30% vs 15%; p=0,004). Comparing the oncological results between groups 1 and 2, statistical difference was observed in the incidence of positive surgical margins (10,3% vs 32,5%; p=0,016) and pathological stages (pT2: 94,8% vs 70% and pT3: 5,2% vs 30%; p=0,005). The majority of positive margins in group 1 occurred in pT2 (75%), while this observation was more prevalent in pT3 (77%) in group 2. Conclusions: The transperitoneal approach was more efficient than the extraperitoneal approach for performing laparoscopic radical prostatectomy during the learning curve, but major complications were commoner when this approach was adopted.