Historical Contribution: 1959, Colston, Radical Perineal Prostatectomy

1959
Colston JAC. Radical Perineal Prostatectomy for Early Cancer: Follow-up Study of One Hundred Eight Personal Cases. JAMA. 1959;169(7):700-703.

 
In 1959, Dr. JAC Colston delivered his experience of over 100 radical perineal prostatectomies for the treatment of prostate cancer at the Southeastern Section of the American Urological Association. The transcript of his talk was published in the Journal of the American Medical Association (JAMA).

Prior to the advent of PSA testing, the diagnosis of prostate cancer relied on physical examination (digital rectal examination) as symptoms do not present until an advanced stage. Colston explains,

"Unfortunately, the progress of prostatic carcinoma is a slow and insidious one, as is well known, and symptoms from a neoplasm usually do not occur until the growth has progressed beyond the capsule of the gland, making a complete eradication of the disease impossible."

The diagnostic rate for curable prostate cancer was reported as low as 5% in the general population. Over the same time period, >40% of men diagnosed at Walter Reed Army Hospital were diagnosed with curable disease – as all men >40 years old were subjected to annual digital rectal examination. At the Brady Urological Institute, the rate of curable disease was 22%.

During this time period, there were no reliable diagnostic biopsies available. Transurethral resections were unreliable as most cancers were found peripherally. Perineal needle biopsy yielded insufficient amounts of tissue for analysis (and tumor seeding through the perineum was observed). Transrectal biopsies were just being undertaken, but at this time involved an incision into the rectal mucosa to reach the prostate. The paradigm at Johns Hopkins involved perineal exposure of the prostate, excisional biopsy and confirmation of carcinoma to be followed by radical prostatectomy in the same setting if cancer was present. Preoperative evaluation included: (1) metastatic survey (serum acid phosphatase and xray), (2) discussion of impotence and possible incontinence following surgery and (3) evaluation of life expectancy. As early as the 1950's, Colston and others recognized that the benefit to treating men over 70 years old, unless in the best of health, was limited.

Colston briefly reviews the existing literature regarding survival following treatment for "curable" prostate cancer:

• Jewett, Johns Hopkins, 1954: 401 radical perineal prostatectomies (starting with HH Young in 1904), 50% 10-year survival approximates that of the general population. [1]
• Turner and Belt, 1957: 274 radical perineal prostatectomies: 47% 10-year survival. [2]
• Barnes, 1953: 31 patients with "resectable" disease treated with hormone therapy only, 50% 5-year survival, 22% 10-year survival. [3]

Colston then presents his experience with 108 patients over a 15-year period. Not only does this demonstrate his "learning curve," but interestingly highlights a phenomenon of survival bias – "After the first 5 years the incidence of death from the disease progressively diminished, and if a patient has survived 10 years his chances of death from carcinoma are minimal."

Colston also delivers very important perioperative and functional outcomes. There are no operative mortalities in his series (typically in the range of 4-5% for this operation), and no instances of serious hemorrhage. Ten patients were completely incontinent after the operation (all were impotent) – a high proportion by today's standards but low for that era of prostate surgery! Colston indicated that avoiding muscles of the external sphincter helped restore continence in many of his patients – an observation that would later be confirmed and exploited by Dr. Patrick C. Walsh to usher in the modern era of radical prostatectomy with minimal risk of incontinence.

Colston concluded:

The postoperative course and follow-up studies on 108 patients subjected to radical perineal prostatectomy have been analyzed. There has been no operative mortality in this series. Perineal exposure and frozen section biopsy were found to be superior to other methods of early diagnosis. The 10-year survival rate in this series is 47%, which closely approximates the life expectancy in normal individuals in this age group.

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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! 

 
[1] Jewett, H. J.: Radical Perineal Prostatectomy for Carcinoma: Analysis of Cases at Johns Hopkins Hospital, 1904-1954, J. A. M. A. 156:1039-1041 (Nov. 13) 1954.
[2] Turner, R. D., and Belt, E.: Study of 229 Consecutive Cases of Total Perineal Prostatectomy for Cancer, J. Urol. 77:62-77 (Jan.) 1957.
[3] Barnes, R. W.: Results of Palliative Treatment of Early Carcinoma of Prostate, J. Urol. 70:489-490 (Sept.) 1953.