S C I E N T I F I C ARTICLES
MORBIDITY OF MODIFIED PELVIC LYMPHADENECTOMY AND RADIOTHERAPY FOR PROSTATIC CANCER MAURIZIO BRAUSI, M.D. MARK S. SOLOWAY, M.D. From the Department of Urology, University of Tennessee, Memphis, the Memphis Veterans Affairs Hospital, and Baptist Memorial Hospital, Memphis, Tennessee
C T--The records of 63 patients treated by pelvic lymphadenectomy and radiotherapy at ty of Tennessee, Memphis, Baptist Memorial Hospital of Memphis, and the Memphis ~e~ Affairs Hospital were reviewed. Of those patients, 45 received external beam radiation ~qpO to the prostate while 16 were treated by Iodine-125 implantation. Two patients had only ~yii~: l mphadenectomy. The incidence of postoperative and late complications were analyzed.
~ibersi
io lymphadenectomy is the most accurate i ~ for determining the presence of lymph !~'!metastases in prostate cancer. Data from :!~rature indicate that complications of this Ni~Ue range from 4 percent to 50 percent !!~~ean of 27 pereent.I ~dard pelvic lymph node dissectioneoni~i~removal of the common iliae,external '~i~iypogastric,and obturator nodes.2 Modi!yi~phadeneetomy as describedby Paulson 3 ~{~hedissectionto the medial margin of the !'~miiliaevein and includes the nodes surImdlng the obturator nerve. This results in a ~r:naorbidity, particularly if external beam ~!gt~6n therapy is subsequently delivered ~)~r Complication rate associated with modi~%ivic lymphadenectomy and Iodine-125 ~I~fitation and/or external beam radiation ~ n particularly low, and we believe it is ~p~0eedure of choice for accurate staging of ~state cancer when the presence of regional ftasiases will alter the treatment strategy. Material and Methods ~rorn 1978 to 1984, 63 patients with prostatic ~einorna were treated by modified lymphade}%'~LOCy /
APRIL 1991
/
VOLUME XXXVII, NUMBER 4
nectomy and radiotherapy at the University of Tennessee, Memphis, Baptist Memorial, and Veterans Affairs Hospital. The mean age was sixty-three years with a range of fifty-three to seventy-five years. Prostatic cancer was diagnosed in 33 patients by needle biopsy, in 25 by transurethral resection (TUR), and in 5 by both techniques. All patients had a complete physical examination, blood urea nitrogen, serum creatinine, alkaline and acid phosphatase, and a complete blood count. Further studies included excretory urography, bone scan, and cystoscopy. Computerized tomography (CT) scan was utilized only when the local tumor was large (Stage C3). Pelvic lymph node dissection was performed by the extraperitoneal route through an infraumbilical midline incision. All the tissue over and under the external iliac vein and surrounding the obturator nerve was included in the dissection. Hemovacs were used for drainage. Antibiotic therapy was initiated one to two hours prior to surgery and continued for fortyeight hours after surgery. Heparin was not routinely given during the postoperative interval. 297
TABLEI. Postoperativeand late complications after pelvic lymphadenectomy and 1~5I implantation in 16 patients --CasesComplications No. Percent Postoperative complications Hematuria 2 12.5 Severe proctitis 2 12,5 Obstructive symptoms 1 6.0 TOTALS 5 31 Late complications
Voiding symptoms (requiring TURP) Severe proctitis (requiring colostomy) Urethral-rectal fistula (ileal conduit) Severe proctitis Perivesical abscess (surgical drainage) TOTAL
4
25
2
12.5
1 1
6 6
1 9
6 56
Sixty-one patients had a bilateral lymphadenectomy while 2 had a unilateral dissection. Forty patients were treated with external beam radiation therapy using a linear accelerator; 5 patients received cobalt. The selection criteria and modalities of the technique have been previously described. 4 Sixteen patients received 125Iimplantation at the time of lymphadenectomy. The technique was that described by Whitmore, Hilaris, and Grabstald. s Two patients had only lymphadenectomy. The clinical stage was A2 in 2 patients, B1 in 3 patients, B2 in 10, C in 17, and 31 were pathologic Stage D1. Follow-up has ranged from twenty-four to one hundred twenty months. Results Complications were divided into two categories: (1) perioperative and (2) those occurring after radiotherapy (125I implant or external beam). No intraoperative complications or deaths were observed during the sixty-three pelvic lymph node dissections. Complications in the postoperative period included 2 patients (3 %) with mild penile and scrotal edema, 5 patients (8 % ) with wound infection, and i patient with bilateral ankle edema. Immediate and late complications after lymph node dissection and ~5I implantation are summarized in Table I. qYansient voiding syrup298
toms including dysuria, frequency, and urgeni as well as mild rectal discomfort were repot!! by most patients. Symptomatic therapy N successful in the great majority. The imrnedil~ complications consisted in 2 cases of persist~ gross hematuria, one of which required transi sion. Another patient presented with obstr~ tive symptoms requiring temporary cathdi~ ization. ;i We considered late complications th'i which occurred at least six months after lyre adenectomy and 125I implantation. Four tients presented with obstructive voiding sy~ toms requiring transurethral resection of: prostate (3 patients) or bladder neck (1 patiei In 2 patients, severe proctitis persisted andi ostomy was performed two and three years i lowing x~sI. One patient presented witf urethral rectal fistula which was treated urinary diversion (ileal conduit). A perivesj abscess developed four years postsurgery ii patient. Surgical drainage was curative, Complications after pelvic lymph node~ section and external beam radiation therap~!l outlined in Table II. Most of the patien~.... received external beam radiotherapy i plained of early side effects which were tr~ symptomatically. Diarrhea (mild), rectal b] ing, dysuria with frequency and urgency the most common symptoms observed di TABLEII. Complications after lymphaden~ and external beam radiation therapy in 45 p__~ Complications Immediate Radiation cystitis and proctitis Pedal and serotal edema Bilateral renal obstruction TOTAL Late Periurethral fistula with scrotal edema Obstructive symptoms (requiring TURP) Pedal edema Bowel obstruetion Radiation cystitis and proctitis with bowel obstruction (surgery) Severe radiation cystitis, proctitis and bilateral leg edema " bladder neck obstruction Severe proctitis TOTAL
UROLOGY
/
APRIL 1991
/
VOLL . . . . . . . . . . . . .
No. ~ 2 2 2 6
1 1 2 1 1
....
• " . . . . . atients presented with de,toms and proctitis six nt. Treatment was symplower extremity and ~re noted in 2 patients. In .1 u r e t e r a l o b s t r u c t i o n ur months after lymphad:herapy. Double J stents lieve obstruction. cations developed in 8 of vo had a small-bowel obLral fistula with penoseroed in another patient and ing catheter. Pedal edema ~nts two years after treataplained of obstructive Lransurethral resection of :) and bladder neck (1 paion proetitis occurred in 2 tiation cystitis developed lplieations were observed ~eeived lymphadeneetomy
mment demonstrated great ac~dal extension of primary wo large series, 6,7 the acae ranged between 70 and ~ificity of 90 percent and a 60 percent. Thus many lymph node dissection as to determine regional ex,~ancer. Pelvic lymphade~ported to be associated idity. Paul and associates 1 : (7 different studies) who nphadenectomy and obons with a mean morbid. However, the complica4 to 53 percent. 8-t3 The ~n seemed to play an imtriation of results. Middleton n and Brendler led technique of dissection ~val of the external iliac percent and 3.9 percent ~speetively. the external iliae n o d e s vere found in 27 percent ents who underwent stag7. 8'14-16 This indicates that les are not dissected, a sig-
..........
/
VOLUME XXXVII, NUMBER 4
nificant percent of mierometastasis may remain unrecognized. These findings, however, were not confirmed by other studies, and the current thinking is that a more limited node dissection can provide accurate staging with minimal risk to the patient.12 Wound infection has been the most frequent complication of lymph node dissection. 1'9'17 Babcock and Grayhack 9 observed an incidence of 22 percent of w o u n d complications, e.g., infection, w o u n d dehiscence, partial faseial separation, hematoma, and seroma in 100 cases. This experience was confirmed b y Paul et al.X and Hilaris and Whitmore ~7 who found 17 percent and 18 percent, respectively, of w o u n d m o r b i d i t y rate. W o u n d drains, u r i n a r y tract infections, metabolic diseases such as diabetes and obesity, and corticosteroid therapy were associated with increased risk of w o u n d complications. Lymphoceles have been noted to be one of the most important complications following node dissection. Ojeda et al. ~8 observed its occurrence in 15 percent of 61 patients who underwent lymphadenectomy. In our study, the overall complication rate was 12 percent including 5 (8 %) w o u n d infections. Penoscrotal and/or lower extremity edema was not a significant complication, occurring only in 2 patients
(3%). W h e n we added 1~5I implantation, an increased morbidity was observed. Fowler et al. ~9 reported a 57 percent morbidity in more than 300 patients. Intra- and postoperative bleeding was significant. Transfusions were required in 40 percent of patients, and the mean blood volume transfused was 1,248 mL. The incidence of intraoperative complications was 6 percent; in 23 percent of patients postoperative complications developed with two deaths. Late complications occurred in 28 percent of patients. Pelvic (lymphoeele or hematoma, abscess, or cellulitis), cardiovascular (pulmonary embolus and thrombophlebitis), and wound complications were the most frequent in the postoperative period. Urinary voiding symptoms, lower extremity or genital edema, and rectal discomfort occurred frequently as late complications after node dissection and ~25I implantation. The morbidity rate after ~5I implantation in our study was 69 percent. No serious bleeding from the prostate was observed during the procedure. Hematuria, severe proetitis, and obstructive symptoms were present in 31 percent of patients in the postoperative period. Late major complications were experienced by 56 % 299
of patients. Interstitial radiation is no longer used by us for the treatment of prostate cancer. Morbidity after external beam radiation therapy primarily involves gastrointestinal, urinary, and sexual function. The reported incidence of bowel complication is 5 to 18 percent. ~9 Voiding symptoms including incontinence affect 6 t o 17 percent of patients.19 Impotence is observed in 23 to 47 percent of patients after external radiation therapyl 2° Protracted genital or lower extremity edema has been reported in 9 to 13 percent in some series. 2~ When lymphadeneetomy was given before radiotherapy the incidence of edema (pedal and penoserotal) was higher. In the series by Freiha 22 and Lieskowsky ~3 and their coworkers, the incidence of these complications was 41 percent and 46 percent, respectively. In our study, immediate complications after lymphadenectomy and external beam radiation was observed in 13 percent while late complications occurred in 18 percent. Pedal and penoscrotal edema were experienced in 4 patients. Severe proctitis was observed in 11 percent and resulted in bowel obstruction in 3 patients. Sexual function was not investigated by US.
Our data confirm the low morbidity of modified lymphadenectomy. External beam supervoltage radiation therapy remains an effective means of treating patients with clinical Stage C prostate cancer. Once the tumor metastasizes to regional lymph nodes the benefit is severely compromised. Iodine-125 implantation has been abandoned at our institution since 1984 due to the high and serious complications observed. Memphis, Tennessee38163
(DR. SOLOWAY) References 1. Paul DB, Loening SA, Narayana AS, and Culp DA: Morbidity from pelvic lymphadenectomy in staging carcinoma of the prostate, J Urol 129:1141 (1983).
300
2. Morales P, and Golimbu M: The therapeutic role of Pelvi lymphadeneetomy in prostate cancer, Urol Clin North Am 7: 6~ (1980). 3. Paulson DF: The prognostic role of lymphadenectomy adenoearcinoma of the prostate, Urol Clin North Am 7: gj (1989). 4. Brausi M, and Soloway MS: Progression and cornplieati01 after external beam radiation therapy for carcinoma of the pr0 tate, Urology 34:115 (1989). 5. Whitmore WF Jr, Hilaris BS, and Grabstald H: Retropui implantation of iodine 125 in the treatment of prostatic canc~ Urol 108:918 (1972). 6. Weinerman PM, et ah Pelvic adenopathy from bladder prostate carcinoma: detection by rapid-sequence computedi~ mography, AJR 140:95 (1983). ~ 7. Golimbu M, Morales P, A1-Askary S, and Shulman ¥:~ scanning in staging of prostatic cancer, Urology 18:305 (198!~ 8. MeLaughlin AP, Saltzstein SL, MeCullough DL, and~Gt: RF: Prostatic carcinoma: incidence and location of unsusp~ ~ lymphatic metastases, J Urol 115:89 (1976). ""~,~ 9. Babcock JR, and Grayhaek JT: Morbidity of peMc lyx~ adenectomy, Urology 13:483 (1979). ": J 10. McCullough DL, McLaughlin AP, and Gittes RF: Mo~ ity of pelvic lymphadenectomy and radical prostatectom~ prostatic cancer, J Urol 117:206 (1977). ~i 11. Wilson CS, Dahl DS, and Middleton RG: PeMc Iyml!1 enectomy for the staging of apparently localized prostatic ea~ J Urol 117:197 (1977). i 12. Brendler CB, Cleeve LK, Anderson EE, and Paulson Staging pelvic lymphadenectomy for carcinoma of the pr~ risk versus benefit, J Urol 124:849 (1980). 13. Lieskowsky R, Skinner DG, and Weisenberger T: 1s lymphadenectomy in the management of carcinoma of th~'~ tare, J Urol 124:635 (1980). ;i 14. Nicholson TC, and Richie JP: Pelvic lymphadcnect0~ stage B1 adenocarcinoma of the prostate: justified or not?:i:, 117:199 (1977). 15. Arduino LJ, and Glucksman MA: Lymph node meii in early carcinoma of the prostate, J Urol 88:91 (1962). 16. Giuliani L: Personal communication, 1989. i'~,: 17. Hilaris B, and Whitmore WF Jr: Radiation therapy, pelvic node dissection in carcinoma of the prostate, Roentgen Radium Ther Nucl Med 121:832 (1974). i 18. Ojeda L, Sharifi R, Lee M, Moiuli K, and Guinan Pphoeele formation after extraperitoneal pelvic lymphadeno possible predisposing factors, J Urol 136:717 (1985). i 19. Fowler JE Jr, Barzell W, Hflaris BJ, and Whitrnore, Complications of 125 iodine implantation and pelvic lym: nectomy in the treatment of prostatic cancer J Urol 1~ (1979). 20. Ray GR, Cassady JR, and Bagshaw MA: Definitivl tion therapy of carcinoma of the prostate. A report on 15! experience, Radiology 106:407 (1973). j 21. Hill DR, Crews QE Jr and Walsh PC' Prostate cag radiation treatment of the primary and regional lympha~ cer 34:156 (1974). '=~ 22. Freiha FS, Pistenma DA, and Bagshaw MA: Pelvic adenectomy for staging prostatic carcinoma: is it alwa~ sary? J Urol 122:176 (1979).
UROLOGY
/ APRIL 1991
/
VOLUME
XXXVII, NIJMI~
MORBIDITY OF MODIFIED PELVIC LYMPHADENECTOMY AND RADIOTHERAPY FOR PROSTATIC CANCER MAURIZIO BRAUSI, M.D. MARK S. SOLOWAY, M.D. From the Department of Urology, University of Tennessee, Memphis, the Memphis Veterans Affairs Hospital, and Baptist Memorial Hospital, Memphis, Tennessee
C T--The records of 63 patients treated by pelvic lymphadenectomy and radiotherapy at ty of Tennessee, Memphis, Baptist Memorial Hospital of Memphis, and the Memphis ~e~ Affairs Hospital were reviewed. Of those patients, 45 received external beam radiation ~qpO to the prostate while 16 were treated by Iodine-125 implantation. Two patients had only ~yii~: l mphadenectomy. The incidence of postoperative and late complications were analyzed.
~ibersi
io lymphadenectomy is the most accurate i ~ for determining the presence of lymph !~'!metastases in prostate cancer. Data from :!~rature indicate that complications of this Ni~Ue range from 4 percent to 50 percent !!~~ean of 27 pereent.I ~dard pelvic lymph node dissectioneoni~i~removal of the common iliae,external '~i~iypogastric,and obturator nodes.2 Modi!yi~phadeneetomy as describedby Paulson 3 ~{~hedissectionto the medial margin of the !'~miiliaevein and includes the nodes surImdlng the obturator nerve. This results in a ~r:naorbidity, particularly if external beam ~!gt~6n therapy is subsequently delivered ~)~r Complication rate associated with modi~%ivic lymphadenectomy and Iodine-125 ~I~fitation and/or external beam radiation ~ n particularly low, and we believe it is ~p~0eedure of choice for accurate staging of ~state cancer when the presence of regional ftasiases will alter the treatment strategy. Material and Methods ~rorn 1978 to 1984, 63 patients with prostatic ~einorna were treated by modified lymphade}%'~LOCy /
APRIL 1991
/
VOLUME XXXVII, NUMBER 4
nectomy and radiotherapy at the University of Tennessee, Memphis, Baptist Memorial, and Veterans Affairs Hospital. The mean age was sixty-three years with a range of fifty-three to seventy-five years. Prostatic cancer was diagnosed in 33 patients by needle biopsy, in 25 by transurethral resection (TUR), and in 5 by both techniques. All patients had a complete physical examination, blood urea nitrogen, serum creatinine, alkaline and acid phosphatase, and a complete blood count. Further studies included excretory urography, bone scan, and cystoscopy. Computerized tomography (CT) scan was utilized only when the local tumor was large (Stage C3). Pelvic lymph node dissection was performed by the extraperitoneal route through an infraumbilical midline incision. All the tissue over and under the external iliac vein and surrounding the obturator nerve was included in the dissection. Hemovacs were used for drainage. Antibiotic therapy was initiated one to two hours prior to surgery and continued for fortyeight hours after surgery. Heparin was not routinely given during the postoperative interval. 297
TABLEI. Postoperativeand late complications after pelvic lymphadenectomy and 1~5I implantation in 16 patients --CasesComplications No. Percent Postoperative complications Hematuria 2 12.5 Severe proctitis 2 12,5 Obstructive symptoms 1 6.0 TOTALS 5 31 Late complications
Voiding symptoms (requiring TURP) Severe proctitis (requiring colostomy) Urethral-rectal fistula (ileal conduit) Severe proctitis Perivesical abscess (surgical drainage) TOTAL
4
25
2
12.5
1 1
6 6
1 9
6 56
Sixty-one patients had a bilateral lymphadenectomy while 2 had a unilateral dissection. Forty patients were treated with external beam radiation therapy using a linear accelerator; 5 patients received cobalt. The selection criteria and modalities of the technique have been previously described. 4 Sixteen patients received 125Iimplantation at the time of lymphadenectomy. The technique was that described by Whitmore, Hilaris, and Grabstald. s Two patients had only lymphadenectomy. The clinical stage was A2 in 2 patients, B1 in 3 patients, B2 in 10, C in 17, and 31 were pathologic Stage D1. Follow-up has ranged from twenty-four to one hundred twenty months. Results Complications were divided into two categories: (1) perioperative and (2) those occurring after radiotherapy (125I implant or external beam). No intraoperative complications or deaths were observed during the sixty-three pelvic lymph node dissections. Complications in the postoperative period included 2 patients (3 %) with mild penile and scrotal edema, 5 patients (8 % ) with wound infection, and i patient with bilateral ankle edema. Immediate and late complications after lymph node dissection and ~5I implantation are summarized in Table I. qYansient voiding syrup298
toms including dysuria, frequency, and urgeni as well as mild rectal discomfort were repot!! by most patients. Symptomatic therapy N successful in the great majority. The imrnedil~ complications consisted in 2 cases of persist~ gross hematuria, one of which required transi sion. Another patient presented with obstr~ tive symptoms requiring temporary cathdi~ ization. ;i We considered late complications th'i which occurred at least six months after lyre adenectomy and 125I implantation. Four tients presented with obstructive voiding sy~ toms requiring transurethral resection of: prostate (3 patients) or bladder neck (1 patiei In 2 patients, severe proctitis persisted andi ostomy was performed two and three years i lowing x~sI. One patient presented witf urethral rectal fistula which was treated urinary diversion (ileal conduit). A perivesj abscess developed four years postsurgery ii patient. Surgical drainage was curative, Complications after pelvic lymph node~ section and external beam radiation therap~!l outlined in Table II. Most of the patien~.... received external beam radiotherapy i plained of early side effects which were tr~ symptomatically. Diarrhea (mild), rectal b] ing, dysuria with frequency and urgency the most common symptoms observed di TABLEII. Complications after lymphaden~ and external beam radiation therapy in 45 p__~ Complications Immediate Radiation cystitis and proctitis Pedal and serotal edema Bilateral renal obstruction TOTAL Late Periurethral fistula with scrotal edema Obstructive symptoms (requiring TURP) Pedal edema Bowel obstruetion Radiation cystitis and proctitis with bowel obstruction (surgery) Severe radiation cystitis, proctitis and bilateral leg edema " bladder neck obstruction Severe proctitis TOTAL
UROLOGY
/
APRIL 1991
/
VOLL . . . . . . . . . . . . .
No. ~ 2 2 2 6
1 1 2 1 1
....
• " . . . . . atients presented with de,toms and proctitis six nt. Treatment was symplower extremity and ~re noted in 2 patients. In .1 u r e t e r a l o b s t r u c t i o n ur months after lymphad:herapy. Double J stents lieve obstruction. cations developed in 8 of vo had a small-bowel obLral fistula with penoseroed in another patient and ing catheter. Pedal edema ~nts two years after treataplained of obstructive Lransurethral resection of :) and bladder neck (1 paion proetitis occurred in 2 tiation cystitis developed lplieations were observed ~eeived lymphadeneetomy
mment demonstrated great ac~dal extension of primary wo large series, 6,7 the acae ranged between 70 and ~ificity of 90 percent and a 60 percent. Thus many lymph node dissection as to determine regional ex,~ancer. Pelvic lymphade~ported to be associated idity. Paul and associates 1 : (7 different studies) who nphadenectomy and obons with a mean morbid. However, the complica4 to 53 percent. 8-t3 The ~n seemed to play an imtriation of results. Middleton n and Brendler led technique of dissection ~val of the external iliac percent and 3.9 percent ~speetively. the external iliae n o d e s vere found in 27 percent ents who underwent stag7. 8'14-16 This indicates that les are not dissected, a sig-
..........
/
VOLUME XXXVII, NUMBER 4
nificant percent of mierometastasis may remain unrecognized. These findings, however, were not confirmed by other studies, and the current thinking is that a more limited node dissection can provide accurate staging with minimal risk to the patient.12 Wound infection has been the most frequent complication of lymph node dissection. 1'9'17 Babcock and Grayhack 9 observed an incidence of 22 percent of w o u n d complications, e.g., infection, w o u n d dehiscence, partial faseial separation, hematoma, and seroma in 100 cases. This experience was confirmed b y Paul et al.X and Hilaris and Whitmore ~7 who found 17 percent and 18 percent, respectively, of w o u n d m o r b i d i t y rate. W o u n d drains, u r i n a r y tract infections, metabolic diseases such as diabetes and obesity, and corticosteroid therapy were associated with increased risk of w o u n d complications. Lymphoceles have been noted to be one of the most important complications following node dissection. Ojeda et al. ~8 observed its occurrence in 15 percent of 61 patients who underwent lymphadenectomy. In our study, the overall complication rate was 12 percent including 5 (8 %) w o u n d infections. Penoscrotal and/or lower extremity edema was not a significant complication, occurring only in 2 patients
(3%). W h e n we added 1~5I implantation, an increased morbidity was observed. Fowler et al. ~9 reported a 57 percent morbidity in more than 300 patients. Intra- and postoperative bleeding was significant. Transfusions were required in 40 percent of patients, and the mean blood volume transfused was 1,248 mL. The incidence of intraoperative complications was 6 percent; in 23 percent of patients postoperative complications developed with two deaths. Late complications occurred in 28 percent of patients. Pelvic (lymphoeele or hematoma, abscess, or cellulitis), cardiovascular (pulmonary embolus and thrombophlebitis), and wound complications were the most frequent in the postoperative period. Urinary voiding symptoms, lower extremity or genital edema, and rectal discomfort occurred frequently as late complications after node dissection and ~25I implantation. The morbidity rate after ~5I implantation in our study was 69 percent. No serious bleeding from the prostate was observed during the procedure. Hematuria, severe proetitis, and obstructive symptoms were present in 31 percent of patients in the postoperative period. Late major complications were experienced by 56 % 299
of patients. Interstitial radiation is no longer used by us for the treatment of prostate cancer. Morbidity after external beam radiation therapy primarily involves gastrointestinal, urinary, and sexual function. The reported incidence of bowel complication is 5 to 18 percent. ~9 Voiding symptoms including incontinence affect 6 t o 17 percent of patients.19 Impotence is observed in 23 to 47 percent of patients after external radiation therapyl 2° Protracted genital or lower extremity edema has been reported in 9 to 13 percent in some series. 2~ When lymphadeneetomy was given before radiotherapy the incidence of edema (pedal and penoserotal) was higher. In the series by Freiha 22 and Lieskowsky ~3 and their coworkers, the incidence of these complications was 41 percent and 46 percent, respectively. In our study, immediate complications after lymphadenectomy and external beam radiation was observed in 13 percent while late complications occurred in 18 percent. Pedal and penoscrotal edema were experienced in 4 patients. Severe proctitis was observed in 11 percent and resulted in bowel obstruction in 3 patients. Sexual function was not investigated by US.
Our data confirm the low morbidity of modified lymphadenectomy. External beam supervoltage radiation therapy remains an effective means of treating patients with clinical Stage C prostate cancer. Once the tumor metastasizes to regional lymph nodes the benefit is severely compromised. Iodine-125 implantation has been abandoned at our institution since 1984 due to the high and serious complications observed. Memphis, Tennessee38163
(DR. SOLOWAY) References 1. Paul DB, Loening SA, Narayana AS, and Culp DA: Morbidity from pelvic lymphadenectomy in staging carcinoma of the prostate, J Urol 129:1141 (1983).
300
2. Morales P, and Golimbu M: The therapeutic role of Pelvi lymphadeneetomy in prostate cancer, Urol Clin North Am 7: 6~ (1980). 3. Paulson DF: The prognostic role of lymphadenectomy adenoearcinoma of the prostate, Urol Clin North Am 7: gj (1989). 4. Brausi M, and Soloway MS: Progression and cornplieati01 after external beam radiation therapy for carcinoma of the pr0 tate, Urology 34:115 (1989). 5. Whitmore WF Jr, Hilaris BS, and Grabstald H: Retropui implantation of iodine 125 in the treatment of prostatic canc~ Urol 108:918 (1972). 6. Weinerman PM, et ah Pelvic adenopathy from bladder prostate carcinoma: detection by rapid-sequence computedi~ mography, AJR 140:95 (1983). ~ 7. Golimbu M, Morales P, A1-Askary S, and Shulman ¥:~ scanning in staging of prostatic cancer, Urology 18:305 (198!~ 8. MeLaughlin AP, Saltzstein SL, MeCullough DL, and~Gt: RF: Prostatic carcinoma: incidence and location of unsusp~ ~ lymphatic metastases, J Urol 115:89 (1976). ""~,~ 9. Babcock JR, and Grayhaek JT: Morbidity of peMc lyx~ adenectomy, Urology 13:483 (1979). ": J 10. McCullough DL, McLaughlin AP, and Gittes RF: Mo~ ity of pelvic lymphadenectomy and radical prostatectom~ prostatic cancer, J Urol 117:206 (1977). ~i 11. Wilson CS, Dahl DS, and Middleton RG: PeMc Iyml!1 enectomy for the staging of apparently localized prostatic ea~ J Urol 117:197 (1977). i 12. Brendler CB, Cleeve LK, Anderson EE, and Paulson Staging pelvic lymphadenectomy for carcinoma of the pr~ risk versus benefit, J Urol 124:849 (1980). 13. Lieskowsky R, Skinner DG, and Weisenberger T: 1s lymphadenectomy in the management of carcinoma of th~'~ tare, J Urol 124:635 (1980). ;i 14. Nicholson TC, and Richie JP: Pelvic lymphadcnect0~ stage B1 adenocarcinoma of the prostate: justified or not?:i:, 117:199 (1977). 15. Arduino LJ, and Glucksman MA: Lymph node meii in early carcinoma of the prostate, J Urol 88:91 (1962). 16. Giuliani L: Personal communication, 1989. i'~,: 17. Hilaris B, and Whitmore WF Jr: Radiation therapy, pelvic node dissection in carcinoma of the prostate, Roentgen Radium Ther Nucl Med 121:832 (1974). i 18. Ojeda L, Sharifi R, Lee M, Moiuli K, and Guinan Pphoeele formation after extraperitoneal pelvic lymphadeno possible predisposing factors, J Urol 136:717 (1985). i 19. Fowler JE Jr, Barzell W, Hflaris BJ, and Whitrnore, Complications of 125 iodine implantation and pelvic lym: nectomy in the treatment of prostatic cancer J Urol 1~ (1979). 20. Ray GR, Cassady JR, and Bagshaw MA: Definitivl tion therapy of carcinoma of the prostate. A report on 15! experience, Radiology 106:407 (1973). j 21. Hill DR, Crews QE Jr and Walsh PC' Prostate cag radiation treatment of the primary and regional lympha~ cer 34:156 (1974). '=~ 22. Freiha FS, Pistenma DA, and Bagshaw MA: Pelvic adenectomy for staging prostatic carcinoma: is it alwa~ sary? J Urol 122:176 (1979).
UROLOGY
/ APRIL 1991
/
VOLUME
XXXVII, NIJMI~
