October 30, 2014

   A Publication of the James Buchanan Brady
   Urological Institute Johns Hopkins Medical Institutions

Volume 1, Winter 2005


Did You Participate in These Studies?

One of the nicest things about our patients at the Brady is their willingness to help us learn more—so we can do a better job of helping them recover from prostate cancer and get on with their lives. Many of the readers of this publication have been generous partners in our process of discovery— even participating in one or more of our studies. How have those studies turned out?

Earlier recovery of sexual function: This study, led by urologist J. Kellogg Parsons, M.D., asked a very simple question: Could steroids, which have been helpful in other types of neurological injury, help men recover sexual function after radical prostatectomy? The 70 men in this study received either a short course of high-dose steroids, or a placebo immediately after surgery. The good news is that the steroids did not cause any side effects; however, they didn’t improve the recovery of sexual function, either. One year later, 74 percent of the men on steroids, compared to 71 percent of the men on placebo, were potent. These results are not significantly different. However, they do confirm earlier Brady studies that show excellent recovery of sexual function at one year. In earlier studies, 70 to 75 percent of men were potent at one year, and by 18 months, 86 to 90 percent were potent. The results also confirm the excellent recovery of urinary control shown in earlier studies. At one year after surgery, 96 to 100 percent were wearing no pads.

For pain after surgery, continuous local anesthetic: In this study, a small catheter was placed in the incision after radical prostatectomy. The catheter, which was left in place for three days, was attached to an elastic pump that dispensed either a local anesthetic (0.5 percent bupivacaine) or a harmless saline solution.

“Somewhat to our surprise, we learned that men with higher hemoglobin levels did not appear to recover faster, have less fatigue, or improved aerobic capacity.”

(The study was “doubleblind,” which means neither doctors nor patients knew which man was receiving the placebo.) One hundred men were randomized to receive either the local anesthetic or the placebo. “It was a great idea,” says Patrick C. Walsh, M.D. “Wouldn’t it be wonderful if it were possible to give local anesthesia directly to the wound, and avoid the side effects of intravenous and oral narcotics?” Unfortunately, he adds, “that is not the way it worked out.” The men who received the anesthetic did not need fewer narcotics for pain relief, and their pain scores did not show any significant improvement. “To all of the men who made this study possible, thank you,” says Walsh. He believes that if the catheter were placed more superficially in the subcutaneous tissue, rather than on top of the muscles, it might prove more helpful.

Who needs a transfusion after surgery? A bit of background before we tell this story: The main deciding factor on who needs a transfusion is the concentration of red blood cells in the blood, and there are two ways to determine this.

“This is an important study, because it may result in fewer patients requiring transfusions.”

One is the hematocrit, the percentage of red blood cells in the blood; the normal hematocrit is about 45 percent. The other critical measurement is the amount of hemoglobin in the blood. Hemoglobin is the major component of red blood cells, and the normal level is around 15 grams per deciliter (g/dl). It is well known that if a man’s hemoglobin falls lower than 6 to 8 g/dl, he has a higher risk of having a heart attack. Traditionally, then, this has been the primary trigger point for transfusions. However, because that hemoglobin count is only half of normal, doctors have worried that men who are anemic at this level might have greater fatigue, and take longer to recover from surgery. Thus, Brady surgeons have traditionally used a hemoglobin cutoff of 10 g/dl as the trigger point for giving patients back their own blood.

In a recent study, 184 men were randomly chosen to receive transfusions either when their hemoglobin was less than 7.5 g/dl, or less than 10 g/dl. The men completed qualityof- life questionnaires after surgery. “Somewhat to our surprise, we learned that men with higher hemoglobin levels did not appear to recover faster, have less fatigue, or improved aerobic capacity,” comments Walsh. “This is an important study, because it may result in fewer patients requiring transfusions.” These results also may reduce the need for men to donate blood before surgery. “In this modern era of surgery, with our current understanding of the anatomy, only a small number of men would require a blood transfusion if the trigger point were set at 7.5 g/dl.”

 

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