Journal of the American Academy of Physician Assistants:
CLINICAL AND PROFESSIONAL GALLERY: Original Research
Mathe, M.; Capello, S.; Greene, T.; Patel, H.; Joseph, J.
University of Rochester Medical Center, Rochester, New York
Introduction: Preoperative clinical staging often lacks correlation with postoperative pathological staging. Office digital rectal examination is also often inaccurate, due to patient discomfort, body habitus, among other factors. In this study, we sought to determine whether intraoperative DRE provides additional information in optimizing outcome of patients undergoing robot‐assisted radical prostatectomy.
Methodology: Office and intraoperative DRE information were reviewed for all patients undergoing RARP by a single surgeon from July 2003 to March 2007. Those patients for whom office and intraoperative DRE information were available were reviewed. Patients were divided into groups based on office clinical stage to define those with T1c versus clinically palpable disease. They were then compared with respect to preoperative, intraoperative, pathologic, and postoperative parameters.
Results: 833 patients had DRE findings available. 605 patients had a negative examination (73%), while 27% had a palpable abnormality. Of those with a negative office DRE, 80.5% had a negative intraoperative examination (true negative, group 1), while 19.5% had a palpable abnormality (false negative, group 2). Of those with a palpable prostate abnormality in the office, 25% had a negative intraoperative examination (false positive, group 3). There was no statistically significant difference in age, body mass index, operating room time, estimated blood loss, neurovascular bundle (NVB) sparing, specimen weight, stage, positive margin rate, and recurrence rate. A greater number of patients in groups 1 (55.8 % bilateral, 26.3 % unilateral) and 3 (55.8 % bilateral, 26 % unilateral) had NVB sparing compared to group 2 (14.7 % bilateral, 48 % unilateral). More patients in group 2 had T3 disease versus groups 1 and 3. Although PSA was lowest in group 3 (5.9), only groups 1(PSA 6.3) and 2 (PSA 7.4) were statistically significant. Group 2 had a higher pathologic grade and stage, with more patients having pT3 disease, when compared to both groups 1 and 3.
Conclusions: Intraoperative DRE helps detect abnormalities in many patients with negative office DRE. Conversely, by detecting false positive office DRE, some men may benefit from a nerve sparing procedure. With the inability to palpate the prostate during RARP, DRE should be routinely performed under anesthesia since it may dictate the extent of surgical resection.
© 2008 Lippincott Williams & Wilkins, Inc.