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10.1245/ASO.2005.10.010
Annals of Surgical Oncology 12:674-678 (2005)
© 2005 Society of Surgical Oncology
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Original Article

Surgical Treatment for Prostate Cancer in Patients With Prior Spinal Cord Injury

Steven R. Gammon, BS1, Kimberly C. Berni, MD2, Katherine S. Virgo, PhD1,3 and Frank E. Johnson, MD1,3

1 Department of Surgery, Saint Louis University Health Science Center, 3635 Vista Avenue, St. Louis, Missouri 63110-0250
2 Division of Urology, Saint Louis University Health Sciences Center, 3635 Vista Avenue, St. Louis, Missouri 63110-0250
3 Surgical Service, Department of Veterans Affairs, Medical Center, (112 JC) 915 North Grand Boulevard, St. Louis, Missouri 63106

Correspondence: Address correspondence and reprint requests to: Frank E. Johnson, MD, Department of Surgery, Saint Louis University Health Science Center, 3635 Vista Avenue, St. Louis, MO 63110-0250; E-mail: frank.johnson{at}med.va.gov


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background: Limited published information is available concerning the clinical course of spinal cord–injured (SCI) patients who develop prostate carcinoma and subsequently undergo radical surgery. We hypothesized that the choice of surgical treatment and the technical conduct of radical surgery would be influenced by sequelae of SCI and that poorer outcomes would result in this population as compared with neurally intact patients.

Methods: A nationwide study was conducted of all SCI veterans receiving care at Department of Veterans Affairs Medical Centers who subsequently developed prostate carcinoma and underwent curative-intent radical operations between 1993 and 2002. Only patients with complete SCI due to trauma who met American Spinal Injury Association type A criteria were analyzed. The unpaired t-test was used to analyze data.

Results: Of 16,878 patients who underwent radical operations for prostate cancer, 55 had preexisting diagnostic codes for SCI. After record review, 14 met all inclusion criteria. The mean age was 57 years. All were asymptomatic with clinically organ-confined disease diagnosed by an increased prostate-specific antigen level or abnormal digital rectal examination results. Comorbid conditions were present in 9 (69%) of 13 patients. Twelve underwent radical prostatectomy, and two underwent cystoprostatectomy. There were no operative deaths, but 8 (57%) of 14 had complications (P < .05). The mean length of stay (16 days) was significantly longer (P < .05) than in neurally intact patients.

Conclusions: SCI patients tended to be younger than neurally intact patients with prostate cancer, and the rate of cystoprostatectomy was high. The complication rate was significantly higher and the hospital stay was significantly longer than in neurally intact patients.

Key Words: Spinal cord injury • Prostatectomy • Cystoprostatectomy • Prostate carcinoma • Outcomes


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The incidence of spinal cord injury (SCI) in the United States is just more than 10,000 cases each year. It is estimated that there are approximately 250,000 people with this condition in the United States at present.1 The survival duration of SCI patients has improved dramatically over the past few decades. Historically, mortality was related to renal failure and sepsis associated with urinary tract infections.2 With improvements in urological management, cancer is now a leading cause of death, as it is in the general population.2

Excluding nonmelanoma skin cancer and carcinoma-in-situ, prostate cancer is the most common cancer and the second leading cause of cancer-related death in men in the United States. In the past, it was a rare cause of death among SCI patients, but it is now common.3 Prostate cancer is particularly common in the Department of Veterans Affairs (DVA) medical system. Previous reports have described the current management of various diseases in patients with prior SCI, but, to the authors’ knowledge, there are no reports concerning the clinical course of patients with complete SCI undergoing radical operations for prostate carcinoma.

The literature is sparse regarding the nonsurgical management of patients with the dual diagnosis of prostate cancer and SCI. Treatment of such patients should consider bladder management before and after surgery, as well as the risks posed by comorbid conditions. Surgical approaches in SCI patients may be especially difficult because of pressure ulcers, contractures, ectopic ossification, and sequelae of the event that caused the SCI. Furthermore, urinary tract colonization and chronic prostatitis are common among SCI patients and increase the risk of wound infection. Candidates are selected for prostatectomy if they have organ-confined cancer with at least a 10-year life expectancy. In SCI patients, urinary diversion with cystoprostatectomy should be considered a viable option.

We hypothesized that the choice of surgical treatment in SCI patients would be influenced by sequelae of SCI, that cystoprostatectomy would be a more common choice than among neurally intact patients, and that the results of radical operation would be poorer in SCI patients than in neurally intact patients.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
A nationwide study was conducted of all SCI veterans receiving care at all 163 DVA Medical Centers who subsequently developed prostate carcinoma. Data were extracted from the DVA Patient Treatment File (PTF), a centralized database of all Veterans Affairs (VA) discharges, for fiscal years 1993 to 2002. Additionally, the Beneficiary Identification and Records Location System was used to identify veteran deaths that occurred after discharge from the hospital. The study was approved by the institutional review board.

The search criteria used to identify patients in the PTF were the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)4 diagnostic codes for patients with either paraplegia or quadriplegia (codes 344–344.99) who subsequently developed prostate carcinoma (codes 185–185.99) and who underwent either cystoprostatectomy or radical prostatectomy (codes 57.71 or 60.5–60.59). For the patients identified, we requested copies of discharge summaries, operative reports, and surgical pathology reports for the index hospital stay from the institutions where they received care. The reports were reviewed to determine patient demographics, clinical presentation, evaluation, treatment, and outcomes. It was assumed that if contractures, pressure sores, ectopic ossification, and other sequelae of SCI were not mentioned in any of the three reports, then they were not of significant concern and were effectively absent.

Only patients with complete SCI of traumatic etiology undergoing either radical prostatectomy or cystoprostatectomy for prostate carcinoma were considered assessable. All assessable patients met American Spinal Injury Association (ASIA) type A criteria,5 which denote complete sensory and motor loss below the spinal cord lesion. We excluded those whose SCI was incomplete (ASIA types B to E) or due to nontraumatic causes (such as metastatic cancer, multiple sclerosis, or infection) and those whose medical records had insufficient data to permit analysis.

Data were entered into a computerized database by using SPSS (SPSS Inc., Chicago, IL) to perform statistical analysis. The statistical test used to compare means in our study versus other studies was the unpaired t-test. Significance was set at P < .05.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
A total of 16,878 patients were identified from the PTF with ICD-9-CM codes for cancer of the prostate who subsequently underwent either radical prostatectomy or cystoprostatectomy. Of these, 55 had an ICD-9-CM code for preexisting SCI. Their records were requested; 53 were sent, and 2 could not be located. Four had prostate cancer as an incidental finding after cystoprostatectomy for bladder cancer or chronic infection and were excluded from further analysis, and 35 were excluded for 1 or more of the following: they did not meet ASIA criteria for complete SCI (n = 27), they had an etiology of SCI other than trauma (n = 7), or they had monoplegia (n = 1). Fourteen patients met inclusion criteria and had sufficiently complete clinical data to be considered assessable. Their mean age was 57 years (SD, 5 years; range, 45–66 years) and had a mean number of years since SCI of 25 (SD, 10 years; range, 8–40 years). They form the basis of this article.

All 14 had clinically organ-confined disease detected by an increased prostate-specific antigen (PSA) level or abnormal digital rectal examination results. The clinical features are listed in Table 1Go. One patient had no history recorded but was otherwise assessable. Of the remaining 13 patients with a medical history represented in the discharge summary, 9 (69%) of 13 had coded comorbid diseases. Those 13 patients had a mean preoperative PSA level of 6.9 ng/mL (SD, 4.1 ng/mL; range, 1.7–17.2 ng/mL). Of note, 2 (14%) of 14 patients underwent cystoprostatectomy. Blood loss recorded in 9 (65%) of 14 patient operative reports showed that 8 radical prostatectomy patients lost 1475 mL of blood (standard deviation, 780 mL; range, 700–3000 mL) and 1 cystoprostatectomy patient lost 800 mL of blood. No patient had a clinical stage >T2cN0M0; the pathologic stage was pT3bN0M0 in 3 (21%) of 14 and pT2CN0M0 in 11 (79%) of 14. The mean Gleason score was 6.5 (SD, 1.2; range, 5–9).


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  		TABLE 1. Clinical features of 14 patients with complete spinal cord injury of traumatic etiology who later developed prostate carcinoma and then received either radical prostatectomy or cystoprostatectomy
 
Intraoperative and postoperative complications are listed in Table 2Go and are stratified by type of operation: radical prostatectomy or cystoprostatectomy. Complications were noted in 7 (58%) of 12 radical prostatectomy patients and 1 (50%) of 2 cystoprostatectomy patients. Four of the radical prostatectomy patients had two or more complications noted. Patients receiving radical prostatectomy had a mean length of hospital stay of 15 days (SD, 13 days; range, 3–38 days after an extreme outlier was recoded to the 90th percentile), and the two patients who underwent cystoprostatectomy had hospital stays of 5 and 29 days.


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  		TABLE 2. Complications after radical prostatectomy or after cystoprostatectomy
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Patients with SCI who survive 3 months after injury live an average of 39 years after injury in the United States.6 Because life expectancy and causes of death for SCI patients now approach those of the general population, prostate cancer is a significant concern. Leading causes of death now include pulmonary and cardiovascular diseases, suicide, and neoplasms; 7% of SCI patients in wealthy countries now die of cancer,2 including prostate carcinoma.3 Although the causes of prostate cancer are poorly understood, there is limited evidence that the prevalence is lower among SCI patients than among the general population. Frisbie7 calculated the incidence among SCI patients at a single VA facility. The incidence was 0 per 100 patient-years among 218 patients with complete C2 to T10 SCI and 2.1 per 100 patient-years among 60 patients with complete T11 to S1 SCI (P < .001). Incidence cannot be calculated in the current study, but there were 10 patients with C5 to T10 SCI and 4 patients with T11 to L2 SCI in our series. Small sample size limits the generalizability of our results, but we believe that the results are representative of the VA SCI population with prostate cancer and certainly show that the incidence of prostate cancer in people with high (above T10) SCI is greater than zero.

The ideal candidate for radical prostatectomy is healthy, with biologically significant and specimen-confined disease and a life expectancy ≥10 years. A previous study of 751 non-SCI patients undergoing radical prostatectomy reported that, in approximately 65% of patients, the diagnosis was made between the ages of 60 to 69 years.8 The average age at operation for the current study was 57 years. This may represent selection of younger SCI patients for operation versus diagnosis at a younger age.

The Food and Drug Administration first approved PSA as a screening tool in 1986, and its use is widespread. In this study, an increased PSA level with or without an abnormal digital rectal examination was the predominant indicator of prostate cancer. In a study of 1000 non-SCI men who underwent radical prostatectomy for prostate cancer, the average preoperative serum PSA level was 7.6 ± .2 ng/mL.9 In the current study, the level was virtually the same (6.9 ± 4.1 ng/mL).

Many patients (69%) in this study had one or more additional conditions, including pressure ulcers (43%), contractures (14%), and ectopic ossification (14%). These conditions can increase the risk of morbidity and the complexity of surgery and tend to lengthen hospital stay. This is the most likely reason for the long hospital stays and high rate of complications among our patients. Furthermore, bladder management before and after treatment of prostate carcinoma must be considered before therapy. In this study, 11 of 12 radical prostatectomy patients and 1 of 2 cystoprostatectomy patients managed bladder emptying by catheterization before operation. The remaining two patients already had permanent urinary-diversion systems. These considerations presumably influenced the choice of surgical procedure.

In a 1998 DVA National Surgical Quality Improvement Program study, 9.7% of the urological operations were radical prostatectomies.10 No data were available for cystoprostatectomies, but they were undoubtedly performed mainly for bladder cancer. In the current study, 14% of patients received cystoprostatectomy, which has higher short- and long-term complication rates and typically requires a longer hospital stay than radical prostatectomy.11

Historically, radical prostatectomy has been associated with significant blood loss, which contributes to morbidity. In 2 series that reviewed 14 separate publications on radical prostatectomy, >60% of patients lost ≥1000 mL of blood during operation.12,13 In the current study, the mean blood loss for eight prostatectomy patients was 1475 mL and was 800 mL in the one cystoprostatectomy patient for whom this information was available (see Results).

Rectal, ureteral, and nerve (obturator and femoral) injury are uncommon complications. In reviewing nine radical prostatectomy studies, Shekarriz et al.13 identified rectal and ureteral injury rates of 0% to 5.3% and .05% to 1.6%, respectively. In the current study, no rectal, ureteral, or nerve injuries were mentioned in any of the patient records. Considering the small number of eligible patients, it is impossible to determine whether this difference is significant. Presumably, nerve injuries in complete-SCI patients would go undiagnosed.

In a study of 1000 non-SCI patients undergoing radical prostatectomy, 89% of patients had Gleason scores of 5 to 7.9 In a multivariate analysis, the Gleason grade in the biopsy specimen was the most powerful long-term prognostic factor, surpassing the preoperative PSA level. None of the other variables, including tumor-node-metastasis stage, added significantly to the prognostic model.13 In the current study, 86% of patients had Gleason scores of 5 to 7 (mean, 6.5). All selected patients in our series had low-stage cancers, thus suggesting that the cancer-specific survival rate in SCI patients undergoing surgical treatment for prostate cancer is approximately the same as in neurally uninjured men, assuming that they are appropriately selected for treatment.

Like other large operations, radical prostatectomy has certain major risks, including death.12 In a study of 11,522 men who underwent radical prostatectomy, 27% to 32% of patients had potentially life-threatening events during the 30-day postoperative period.14 In the current study, 57% of patients had one or more complications, and this was a statistically significant difference (P < .05) compared with the results of Begg et al.14 The high complication rate may be partly ascribable to the fact that a typical urologist rarely operates on an SCI patient and may be unfamiliar with the problems common in these patients. The mean length of hospital stay in our study was 15 days for patients who underwent radical prostatectomy and 17 days for patients who underwent cystoprostatectomy. These lengths of stay are significantly longer (P < .001) than those reported by Lepor et al.,9 who found a mean length of hospital stay after radical prostatectomy of 2 days, or those reported by Neulander et al.,15 who found a mean length of hospital stay after cystectomy of 7 days. These longer stays may be ascribable to the higher rates of comorbidities and complications among our SCI patients.


   CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
SCI patients undergoing radical prostatectomy represent a unique challenge. Data from this report and others16,17 suggest that SCI patients have worse outcomes of surgery than neurally intact patients. As life expectancy and causes of death in these patients approach those of the general population, prostate cancer will presumably remain common. In this study, tumor stage and Gleason score in SCI patients were similar to those reported in neurally intact men, but the SCI patients tended to be younger. We hypothesized that the technical conduct of surgery would be compromised in these patients; the only evidence supporting this was the excessive operative bleeding. We hypothesized that poorer outcomes would result; this was supported by the high rate of complications. We assume that the documented comorbid conditions account for these observations. The cystoprostatectomy rate was very high. Radical prostatectomy and cystoprostatectomy patients were analyzed separately, and both were found to have increased complication rates and longer stays. These data were gathered from the 163 DVA medical centers, a non–referral-based national medical system. The DVA system has an excellent centralized computer database mechanism in place to evaluate whether SCI is an independent major risk factor for adverse outcomes of surgical procedures.10 These data comprise the only published series on this topic and suggest that there are important differences in clinical course between prostate cancer patients who are neurally intact and those with SCI. We hope that this article will encourage others to investigate this topic with other larger data sets to increase the credibility and generalizability of our conclusions.

Received for publication October 14, 2004. Accepted for publication February 12, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. De Vivo MJ. Epidemiology of spinal cord injury. In: Lin VW, ed. Spinal Cord Medicine: Principles and Practice. New York: Demos Medical Publishing, 2003:79–85.
  2. Hartkopp A, Bronnum-Hansen H, Seidenschnur AM, Biering-Sorensen F. Survival and cause of death after traumatic spinal cord injury, a long-term epidemiological survey from Denmark. Spinal Cord 1997;35:76–85.[CrossRef][Medline]
  3. Wyndaele JJ, Iwatsubo E, Perkash I, Stohrer M. Prostate cancer: a hazard to be considered in the ageing male patient with spinal cord injury. Spinal Cord 1998;36:299–302.[Medline]
  4. American Medical Association. International Classification of Diseases, Ninth Revision, Clinical Modification. Salt Lake City: St. Anthonys Publishing, Medicode, 1998.
  5. American Spinal Injury Association. International Standard for Neurologic Classification of SCI, Revised 2000. Chicago: American Spinal Injury Association, 2000.
  6. Samsa GP, Patrick CH, Feussner JR. Long-term survival of veterans with traumatic spinal cord injury. Arch Neurol 1993;50:909–14.[Abstract]
  7. Frisbie JH. Cancer of the prostate in myelopathy patients: lower risk with higher levels of paralysis. J Spinal Cord Med 2001;24:92–94[Medline]
  8. Sweat SD, Bergstralh EJ, Slezak J, Blute ML, Zincke H. Competing risk analysis after radical prostatectomy for clinically nonmetastatic prostate adenocarcinoma according to clinical Gleason score and patient age. J Urol 2002;168:525–529[CrossRef][Medline]
  9. Lepor H, Nieder AM, Ferrandino MN. Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1,000 cases. J Urol 2001;166:1729–1733[Medline]
  10. Khuri SF, Daley J, Henderson W, et al. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. Ann Surg 1998;228:491–507[CrossRef][Medline]
  11. Moul JW, Paulson DF. The role of radical surgery in the management of radiation recurrent and large volume prostate cancer. Cancer 1991;68:1265–1271[CrossRef][Medline]
  12. Shekarriz B, Upadhyay J, Wood DP. Intraoperative, perioperative, and long-term complications of radical prostatectomy. Urol Clin North Am 2001;28:639–653[CrossRef][Medline]
  13. Eastham JA, Scardino PT. Radical prostatectomy. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell’s Urology, Eighth Edition. Philadelphia: WB Saunders, 2002: 3080–308.
  14. Begg CB, Riedel ER, Bach PB, et al. Variations in morbidity after radical prostatectomy. N Engl J Med 2002;346:1138–1144[Abstract/Free Full Text]
  15. Neulander EZ, Rivera I, Eisenbrown N, Wajsman Z. Simple cystectomy in patients requiring urinary diversion. J Urol 2000;164:1169–1172[Medline]
  16. Chan JW, Virgo KS, Johnson FE. Hemipelvectomy for severe decubitus ulcers in patients with previous spinal cord injury. Am J Surg 2003;185:69–73.[Medline]
  17. Ahmed HU, Smith JB, Rudderow DJ, et al. Cholecystectomy in patients with previous spinal cord injury. Am J Surg 2002; 184:452–459[Medline]




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