Patrick C. Walsh

In this study we report the prevalence and growth rate of human benign prostatic hyperplasia with age by combining and analyzing data from 10 independent studies containing more than 1,000 prostates. The normal prostate reaches 20 plus or minus 6 gm. in men between 21 and 30 years old, and this weight remains essentially constant with increasing age unless benign prostatic hyperplasia develops. The prevalence of pathological benign prostatic hyperplasia is only 8 per cent at the fourth decade; however, 50 per cent of the male population has pathological benign prostatic hyperplasia when they are 51 to 60 years old. The average weight of a prostate that is recognized at autopsy to contain benign prostatic hyperplasia is 33 plus or minus 16 gm. Only 4 per cent of the prostates in men more than 70 years old reach sizes greater than 100 gm. An analysis of a logistic growth curve of benign prostatic hyperplasia lesions removed at prostatectomy indicates that the growth of benign prostatic hyperplasia is initiated probably before the patient is 30 years old. The early phase of benign prostatic hyperplasia growth (men between 31 and 50 years old) is characterized by a doubling time for the tumor weight of 4.5 years. In the mid phase of benign prostatic hyperplasia growth (men between 51 and 70 years old) the doubling time is 10 years, and increases to more than 100 years in patients beyond 70 years old.

No AccessJournal of Urology1 Sep 1982Impotence Following Radical Prostatectomy: Insight Into Etiology and Prevention Patrick C. Walsh, and Pieter J. Donker Patrick C. WalshPatrick C. Walsh More articles by this author , and Pieter J. DonkerPieter J. Donker More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)53012-8AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail This study was undertaken to identify the cause of impotence in men undergoing radical prostatectomy, with the hope that this information may provide insight into the possible prevention of this complication. The autonomic innervation of the corpora cavernosa in the male fetus and newborn was traced to determine the topographical relationship between the pelvic nerve plexus, and the prostate, urethra and urogenital diaphragm. We have demonstrated that the branches of the pelvic plexus that innervate the corpora cavernosa are situated between the rectum and urethra, and penetrate the urogenital diaphragm near or in the muscular wall of the urethra. Injuries to the pelvic plexus can occur in 2 ways: 1) during division of the lateral pedicle and 2) at the time of apical dissection with transection of the urethra. Thirty-one men who underwent radical retropubic prostatectomy were evaluated to determine risk factors that correlated with postoperative impotence: 5 (16 per cent) were fully potent, 7 (23 per cent) had partial erections that were inadequate for sexual intercourse and 19 (61 per cent) had total erectile impotence. The 2 factors that had a favorable influence on postoperative potency were age and pathologic stage of the lesion: 31 per cent of the patients less than 60 years old were potent versus only 6 per cent of the patients more than 60 years, while 33 per cent of the patients with tumor microscopically confined to the prostatic capsule were potent versus only 5 per cent of those with capsular penetration. When the factors of age and capsular penetration were combined 60 per cent of the men less than 60 years old who had an intact prostatic capsule were potent. Arterial insufficiency and psychogenic factors were excluded as major contributing factors by the finding of normal penile blood flow and absence of nocturnal penile tumescence in the impotent patients. We conclude that impotence after radical prostatectomy results from injury to the pelvic nerve plexus that provides autonomic innervation to the corpora cavernosa. Further studies will be necessary to determine whether refinements in surgical technique, especially during ligation of the lateral pedicle and apical dissection, can prevent this complication. © 1982 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited ByAvulova S, Zhao Z, Lee D, Huang L, Koyama T, Hoffman K, Conwill R, Wu X, Chen V, Cooperberg M, Goodman M, Greenfield S, Hamilton A, Hashibe M, Paddock L, Stroup A, Resnick M, Penson D and Barocas D (2018) The Effect of Nerve Sparing Status on Sexual and Urinary Function: 3-Year Results from the CEASAR StudyJournal of Urology, VOL. 199, NO. 5, (1202-1209), Online publication date: 1-May-2018.Lundgren P, Kjellman A, Norming U and Gustafsson O (2018) Long-Term Outcome of a Single Intervention Population Based Prostate Cancer Screening StudyJournal of Urology, VOL. 200, NO. 1, (82-88), Online publication date: 1-Jul-2018.Lepor H (2016) Surgical Treatment of Prostate CarcinomaJournal of 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Part 2, Online publication date: J, R, D and Walsh P (2018) Nerve Nerve and Erectile Function in of Urology, VOL. NO. 2 Part 1, Online publication date: T (2018) This in of Erectile Function by Cavernous Nerve of Urology, VOL. NO. 2, Online publication date: D, R and Walsh P (2018) Cavernous Nerve Erectile Function in of Urology, VOL. NO. 2, Online publication date: M, R and Walsh P (2018) Impact of Anatomical Radical Prostatectomy on Urinary of Urology, VOL. NO. 3, Online publication date: A (2018) of Urology, VOL. NO. 3, Online publication date: D, Epstein J, B and Walsh P (2018) Sexual Function Radical Prostatectomy: of of Neurovascular of Urology, VOL. NO. 5, Online publication date: R, M and Walsh P (2018) Cancer Anatomical Radical Prostatectomy: An of Urology, VOL. NO. 6, Online publication date: C, P and Walsh P (2018) with of PotencyJournal of Urology, VOL. NO. 2 Part 1, Online publication date: J, R, R, R, J and G (2018) with of of Urology, VOL. NO. 2 Part 1, Online publication date: B, G, B, A and A (2018) of the Urinary on Development and Sexual Function in with of Urology, VOL. NO. 2 Part 2, Online publication date: C, G, F, J and Walsh P (2018) Recurrence and Following Radical of Urology, VOL. NO. 5, Online publication date: S, and W (2018) Role of Radical Prostatectomy for Clinical Prostate CancerJournal of Urology, VOL. NO. 6, Online publication date: M (2018) of Urology, VOL. NO. 2 Part 1, Online publication date: D (2018) of the Anterior for of Urology, VOL. NO. 2 Part 1, Online publication date: A, J, E, F and T (2018) The Role of in the of of Urology, VOL. NO. 3, Online publication date: P and B (2018) Continence Following Radical ProstatectomyJournal of Urology, VOL. NO. 5, Online publication date: J, S, B, Lue T and E (2018) of Neurovascular Surgical of Urology, VOL. NO. 2, Online publication date: D, R, A, J and Walsh P (2018) The as a for the Study of of Urology, VOL. NO. Part 1, Online publication date: and F (2018) Radical Prostatectomy: Surgical and ResultsJournal of Urology, VOL. NO. 3, Online publication date: R (2018) of of Urology, VOL. NO. 1, Online publication date: V, K and A (2018) Urethral after Radical Retropubic ProstatectomyJournal of Urology, VOL. NO. 2, Online publication date: R and W (2018) of Patients Following Radical ProstatectomyJournal of Urology, VOL. NO. 4, Online publication date: J (2018) An Urinary of Urology, VOL. NO. Part 1, Online publication date: P, Epstein J and F (2018) Potency Following Radical Prostatectomy with of the Neurovascular of Urology, VOL. NO. Part 1, Online publication date: E and H (2018) in Canine Insight into Development and of Urology, VOL. NO. Part 2, Online publication date: A (2018) Radical Prostatectomy for in Men More of Urology, VOL. NO. 5, Online publication date: P and Walsh P (2018) to Radical with of Sexual of Urology, VOL. NO. 6, Online publication date: (2018) by of Urology, VOL. NO. 1 Part 1, Online publication date: I and (2018) Treatment for Muscle of the of Urology, VOL. NO. 6, Online publication date: K, P, H, H and F (2018) Cystectomy and Bladder after Preoperative for Bladder CancerJournal of Urology, VOL. NO. 3, Online publication date: and A (2018) Sexual Function and Radical Cystectomy: A of Urology, VOL. NO. 3, Online publication date: J and Walsh P (2018) Radical Prostatectomy with of Sexual Function: in the of Urology, VOL. NO. 6, Online publication date: D and G (2018) of the Prostate: An on of With a Commentary on the of of Urology, VOL. NO. 6, Online publication date: H, M, R, F and Walsh P (2018) of the Autonomic Nerves From the pelvic to the a Anatomical Study of the Male of Urology, VOL. NO. 2, Online publication date: P, Lue T, R, G and J (2018) of Urology, VOL. NO. 2, Online publication date: (2018) by of Urology, VOL. NO. 2, Online publication date: E and Resnick M (2018) Radical ProstatectomyJournal of Urology, VOL. NO. 6, Online publication date: R, R, G and J (2018) Prostatectomy for Localized CancerJournal of Urology, VOL. NO. 1, Online publication date: T, S, R and E (2018) of to of Urology, VOL. NO. 2, Online publication date: H (2018) A View of the of Urology, VOL. NO. 5, Online publication date: T, T and K (2018) Further of the Urethral in Study during and of to of Urology, VOL. NO. 6, Online publication date: E (2018) and the of Urology, VOL. NO. 6, Online publication date: 1982 by The American Urological Association Education and Research, Patrick C. Walsh More articles by this author Pieter J. Donker More articles by this author All

CONTEXT: The natural history of biochemical recurrence after radical prostatectomy can be long but variable. Better risk assessment models are needed to identify men who are at high risk for prostate cancer death early and who may benefit from aggressive salvage treatment and to identify men who are at low risk for prostate cancer death and can be safely observed. OBJECTIVES: To define risk factors for prostate cancer death following radical prostatectomy and to develop tables to risk stratify for prostate cancer-specific survival. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of 379 men who had undergone radical prostatectomy at an urban tertiary care hospital between 1982 and 2000 and who had a biochemical recurrence and after biochemical failure had at least 2 prostate-specific antigen (PSA) values at least 3 months apart in order to calculate PSA doubling time (PSADT). The mean (SD) follow-up after surgery was 10.3 (4.7) years and median follow-up was 10 years (range, 1-20 years). MAIN OUTCOME MEASURE: Prostate cancer-specific mortality. RESULTS: Median survival had not been reached after 16 years of follow-up after biochemical recurrence. Prostate-specific doubling time (<3.0 vs 3.0-8.9 vs 9.0-14.9 vs > or =15.0 months), pathological Gleason score (< or =7 vs 8-10), and time from surgery to biochemical recurrence (< or =3 vs >3 years) were all significant risk factors for time to prostate-specific mortality. Using these 3 variables, tables were constructed to estimate the risk of prostate cancer-specific survival at year 15 after biochemical recurrence. CONCLUSION: Clinical parameters (PSADT, pathological Gleason score, and time from surgery to biochemical recurrence) can help risk stratify patients for prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy. These preliminary findings may serve as useful guides to patients and their physicians to identify patients at high risk for prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy to enroll them in early aggressive treatment trials. In addition, these preliminary findings highlight that survival in low-risk patients can be quite prolonged.

Clinical stage, Gleason score and serum prostate specific antigen (PSA) levels are used separately to predict pathological stage in patients with localized prostate cancer. Because the degree of tumor differentiation has a profound influence on the expression of serum PSA, serum PSA levels alone do not reflect tumor burden accurately. To overcome this obstacle we tested these 3 variables alone and in combinations as predictors of final pathological stage in 703 men with clinically localized prostate cancer at our institution. All patients were assigned a clinical stage by 1 urologist. The Gleason score was determined from preoperative needle biopsy and serum PSA levels were measured on an ambulatory basis. Final pathological stage was determined to be either organ confined, established capsular penetration, seminal vesicle involvement or lymph node involvement. Logistic regression analysis with the likelihood ratio chi-square test determined that serum PSA, Gleason score and clinical stage all predicted final pathological stage well. The results were improved with combinations of the 3 variables (serum PSA, Gleason score and clinical stage) and the combination provided the best separation. From these analyses probability plots and nomograms have been constructed to assist urologists in the preoperative prediction of final pathological stage for patients with clinically localized prostate cancer.

CONTEXT: The percentage of free prostate-specific antigen (PSA) in serum has been shown to enhance the specificity of PSA testing for prostate cancer detection, but earlier studies provided only preliminary cutoffs for clinical use. OBJECTIVE: To develop risk assessment guidelines and a cutoff value for defining abnormal percentage of free PSA in a population of men to whom the test would be applied. DESIGN: Prospective blinded study using the Tandem PSA and free PSA assays (Hybritech Inc, San Diego, Calif). SETTING: Seven nationwide university medical centers. PARTICIPANTS: A total of 773 men (379 with prostate cancer, 394 with benign prostatic disease) 50 to 75 years of age with a palpably benign prostate gland, PSA level of 4.0 to 10.0 ng/mL, and histologically confirmed diagnosis. MAIN OUTCOME MEASURES: A percentage of free PSA cutoff that maintained 95% sensitivity for prostate cancer detection, and probability of cancer for individual patients. RESULTS: The percentage of free PSA may be used in 2 ways: as a single cut-off (ie, perform a biopsy for all patients at or below a cutoff of 25% free PSA) or as an individual patient risk assessment (ie, base biopsy decisions on each patient's risk of cancer). The 25% free PSA cutoff detected 95% of cancers while avoiding 20% of unnecessary biopsies. The cancers associated with greater than 25% free PSA were more prevalent in older patients, and generally were less threatening in terms of tumor grade and volume. For individual patients, a lower percentage of free PSA was associated with a higher risk of cancer (range, 8%-56%). In the multivariate model used, the percentage of free PSA was an independent predictor of prostate cancer (odds ratio [OR], 3.2; 95% confidence interval [CI], 2.5-4.1; P < .001) and contributed significantly more than age (OR, 1.2; 95% CI, 0.92-1.55) or total PSA level (OR, 1.0; 95% CI, 0.92-1.11) in this cohort of subjects with total PSA values between 4.0 and 10.0 ng/mL. CONCLUSIONS: Use of the percentage of free PSA can reduce unnecessary biopsies in patients undergoing evaluation for prostate cancer, with a minimal loss in sensitivity in detecting cancer. A cutoff of 25% or less free PSA is recommended for patients with PSA values between 4.0 and 10.0 ng/mL and a palpably benign gland, regardless of patient age or prostate size. To our knowledge, this study is the largest series to date evaluating the percentage of free PSA in a population representative of patients in whom the test would be used in clinical practice.