Tuesday, August 19, 2014

Historical Contribution: 1943, Colston, Suitability for Radical Prostatectomy


Carcinoma of the prostate - A study of the percentage or cases suitable for the radical operation J. A. C. Colston Journal of the American Medical Association 1943  122: 781-784

Since Hugh Hampton Young's description of the radical perineal prostatectomy in 1904, Johns Hopkins and the Brady Urological Institute was amongst the world leaders in prostate cancer surgery.  When asked to estimate the proportion of patients undergoing radical prostatectomy in 1942, JAC Colston offered that 5% of patients underwent radical surgery.  When he reviewed the records of 300 patients with prostate cancer treated at Johns Hopkins inthe preceding 5 years, he found that, in fact, 20% underwent radical surgery.  This was a dramatic discrepancy from Colston's own estimate in addition to deviation from practice around the country -- the comparable number from the University of Virginia Hospital was 9% over the same time period.

Colston commented on these statistics:
"I realize that this percentage of cases suitable for the radical operation is probably higher than would be seen in other clinics, but it can be explained by the fact that many patients are referred to this clinic with a diagnosis of early carcinoma for the express purpose of undergoing the radical operation."
Colston was also adamant that the operation was performed in patients "considered suitable for the radical operation with a good prognosis for complete cure."  He laid out the following selection criteria for curative radical prostatectomy:

  • organ-confined disease (no locally advanced disease) on clinical examination
  • no evidence of metastases on radiography
  • serum acid and basic phosphatase are within normal limits
  • satisfactory general health ("a fair span of life expectancy")
He also described the palliative operation in cases where cancer extended beyond the tips of the seminal vesicles or invaded the bladder neck.  In both cases, "the patient's subsequent course was much more satisfactory than with any other method of treatment."

Colston also reported the oncologic outcomes:

Interestingly, the only pre-operative prognostic factor was digital rectal examination (DRE).  HH Young was able to dichotomize patients into "good-" or "poor-risk" based on their DRE and this correlated very well with outcome: 41 of 43 patients with a good-risk DRE were alive at last follow-up, while 18 of 26 patients with poor-risk DRE had a cancer recurrence or were dead.

Finally, Colston was also able to report functional outcomes, with good control in most patients.  In addition, a modified suture technique, employed in 1940, resulted in a greater proportion of patients with "good urinary control." 

To read the entire manuscript: follow the link above, visit the Centennial Website or click here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 

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