Serum prostate-specific antigen and the biologic progression of prostate cancer

OBJECTIVES

We have previously shown that serum prostate-specific antigen (PSA) is proportional to prostate cancer volume and that progression of prostate cancer is proportional to volume, but other investigators have not found serum PSA to be as useful in predicting pathologic stage at the time of radical prostatectomy. Because our series is the only study to examine prospectively all radical specimens at 3-mm intervals, we have examined the relationship between serum PSA and the morphologic indicators of cancer progression in our first 350 radical prostatectomies.

METHODS

Preoperative serum PSA level was tabulated in 350 consecutive patients with prostate adenocarcinoma and compared with morphologic variables in the radical prostatectomy specimen. Morphologic variables included cancer volume, histologic grade, capsular penetration, seminal vesicle invasion, and lymph node metastasis.

RESULTS

Serum PSA showed strong correlation with all morphologic variables, which were highly intercorrelated. Serum PSA level was strongly correlated with cancer volume, histologic grade, and frequency of regional spread to lymph nodes. Close intercorrelations found between all variables were translated into a scale relating each level of serum PSA elevation to stage of disease in morphologic terms. Using this scale, serum PSA level can contribute to patient evaluation and treatment decisions in men with prostate cancer.

CONCLUSIONS

Serum PSA is primarily determined by prostate cancer volume and secondarily by the percentage of high-grade cancer (Gleason grades 4 and 5) in the prostate. Because of this basic relationship, serum levels of PSA provide a clinically useful estimate of morphologic findings in the prostate. Serial PSA determinations should reflect the growth of the cancer as well as the gradual evolution of more malignant cells with the passage of time. The use of a serum PSA-based rating scale can contribute to patient evaluation and treatment decisions in men with prostate cancer.

Core cancer length in ultrasound-guided systematic sextant biopsies: a preoperative evaluation of prostate cancer volume

OBJECTIVES

Evidence has been presented that biologic aggressiveness of prostate carcinoma increases with volume and that cancers less than 0.5 cc may be regarded as clinically insignificant for immediate treatment. We have analyzed the ability of core cancer length on needle biopsy to predict cancer volumes near the 0.5 cc threshold for distinction between incidental versus clinical carcinoma.

METHODS

Systematic sextant transrectal ultrasound-guided prostate biopsies were performed on 110 men who then underwent radical prostatectomy for adenocarcinoma. The core cancer length within each biopsy was compared with the volumes of clinical and incidental carcinomas in the prostatectomy specimen.

RESULTS

Among incidental (nonpalpable) cancers, 14% of those under 0.2 cc were detected, but 44% at 0.2 to 0.5 cc and 92% of those more than 0.5 cc were detected. Among clinically suspected carcinomas, 2 mm or longer core cancer length reliably predicted a cancer of 0.5 cc or larger, but among incidental cancers, it predicted a tumor of 0.2 cc or larger. A 3-mm core cancer length threshold predicted 0.5 cc for both groups. The high frequency of incidental cancers under 0.5 cc impaired the predictive value of multiple positive needle cores. Bilateral positive biopsy results indicated bilateral extension of clinical cancer in only 59% of cases.

CONCLUSIONS

A core cancer length of 3 mm or more on one or two needle biopsies reliably predicts cancer of clinically significant volume (0.5 cc or larger). The high detection frequency of smaller incidental carcinomas on biopsy impairs the reliability of volume estimation from multiple positive needle cores and mandates that treatment decisions be made with knowledge of core cancer length.

Incontinence and vesical neck strictures following radical retropubic prostatectomy

OBJECTIVES

To evaluate the incidence and severity of vesical neck strictures and urinary incontinence after radical retropubic prostatectomy (RRP) for prostate cancer.

METHODS

Between August 1983 and December 1991, 481 consecutive patients underwent RRP by 1 of 2 senior surgeons. Strictures were treated by passing a urethral sound. Incontinence was measured by asking patients for a daily "pad count" of pads required to control urinary leakage. Results were compared to patient age, tumor volume, number of neurovascular bundles spared, preoperative urinary complaints, and previous transurethral resection of the prostate.

RESULTS

Of 456 patients with adequate follow-up to determine stricture formation, 82.5% had no strictures, 6.8% required a single dilation, 3.7% required 2 dilations, 3.1% required 3 dilations, and 3.9% required more than 3 dilations. Risk of stricture formation was unrelated to every variable studied. Of 458 patients with adequate follow-up to determine recovery of continence, 80.1% required no pads, 8.1% required 1 to 2 pads a day, 6.6% required 3 to 5 pads a day, and 5.2% were totally incontinent 1 year or more after surgery. Incontinence was closely associated with postoperative urinary urgency.

CONCLUSIONS

Strictures are a common but easily managed complication of RRP for prostate cancer. Despite substantial surgical experience, we report a somewhat higher rate of postoperative incontinence than other recently reported series. Our experience is more closely matched by published surveys of patient-reported complications after RRP.

Ultrasensitive assay of prostate-specific antigen used for early detection of prostate cancer relapse and estimation of tumor-doubling time after radical prostatectomy

We used an ultrasensitive prostate-specific antigen (PSA) assay with a detection limit of 0.02 microgram/L for long-term monitoring of PSA changes in 5 patients who were cured by radical prostatectomy and in 10 patients who had failed prostatectomies; 5 patients who underwent cystoprostatectomy were also evaluated with one sample after surgery. Relapse-free periods, determined on the basis of criteria designed specifically for the ultrasensitive assay or proposed for other currently available PSA assays, were calculated for the patients with failed prostatectomies. Tumor-doubling times were also calculated, postsurgery, according to a model that assumes exponential tumor growth over time. We found that prostate cancer relapse, on average, could be diagnosed 420 or 883 days earlier with the ultrasensitive assay than with assays having detection limits of 0.1 or 0.3 microgram/L, respectively. Tumor-doubling times, calculated after radical prostatectomy, ranged from 67 to 568 days among the 10 patients. We also present evidence that even more-sensitive PSA assays might be able to further reduce the relapse-free periods in approximately 50% of the prostate cancer patients who ultimately relapse.

Ultrasensitive assay of prostate-specific antigen used for early detection of prostate cancer relapse and estimation of tumor-doubling time after radical prostatectomy

We used an ultrasensitive prostate-specific antigen (PSA) assay with a detection limit of 0.02 microgram/L for long-term monitoring of PSA changes in 5 patients who were cured by radical prostatectomy and in 10 patients who had failed prostatectomies; 5 patients who underwent cystoprostatectomy were also evaluated with one sample after surgery. Relapse-free periods, determined on the basis of criteria designed specifically for the ultrasensitive assay or proposed for other currently available PSA assays, were calculated for the patients with failed prostatectomies. Tumor-doubling times were also calculated, postsurgery, according to a model that assumes exponential tumor growth over time. We found that prostate cancer relapse, on average, could be diagnosed 420 or 883 days earlier with the ultrasensitive assay than with assays having detection limits of 0.1 or 0.3 microgram/L, respectively. Tumor-doubling times, calculated after radical prostatectomy, ranged from 67 to 568 days among the 10 patients. We also present evidence that even more-sensitive PSA assays might be able to further reduce the relapse-free periods in approximately 50% of the prostate cancer patients who ultimately relapse.

Indications for ultrasound guided transition zone biopsies in the detection of prostate cancer

Transrectal prostate ultrasound and systematic sextant biopsies have improved peripheral zone cancer diagnosis but they may miss many cancers arising in the transition zone. Biopsies directed into the transition zone have been used to detect residual prostate cancer in patients diagnosed by transurethral resection and they have been suggested as potentially useful additions to systematic sextant biopsies. To define the indications for transition zone biopsies 187 men underwent evaluation including systematic sextant biopsies and transition zone biopsies. These patients were classified into 4 categories based on clinical presentation. Category 1 included 26 men with palpable nodularity and an elevated prostate specific antigen (PSA), of whom 16 (61.5%) had positive biopsies but none was positive only in the transition zone biopsies. Category 2 consisted of 49 men with sonographic abnormalities in the transition zone, of whom 15 (30.6%) had positive biopsies, including 2 (13.3%) with only positive transition zone biopsies. Category 3 consisted of 65 men with normal rectal examination and elevated PSA level, of whom 24 (36.9%) had biopsies positive for cancer, including 8 (33.3%) with only positive transition zone biopsies. Category 4 consisted of 47 men with a clinical presentation highly suspicious of prostatic malignancy but no cancer on prior systematic sextant biopsies, of whom 17 (37.7%) had positive biopsies, including 9 (53.0%) with only positive transition zone biopsies. We conclude that transition zone biopsies are useful in patients with a high suspicion of prostate cancer and negative prior systematic sextant biopsies. Cancer can also be demonstrated in many men with a normal digital rectal examination and an elevated PSA level. Patients with transition zone abnormalities on ultrasound images or palpable nodularity do not have substantially increased cancer detection with the addition of transition zone biopsies.

Correlation between serum prostate specific antigen levels and the volume of the individual glandular zones of the human prostate

To analyze the correlation between serum prostate specific antigen (PSA) levels and the volume of the individual glandular zones of the human prostate, we examined 31 cystoprostatectomy specimens as well as 13 radical prostatectomy specimens with a prostate cancer volume of 0.3 cc or less, no bladder cancer infiltrating the prostate, no granulomas or severe inflammation, as well as no patient history of radiation, transurethral resection of the prostate or hormonal treatment. The volumes of the peripheral zone, transition zone and central zone were separately determined by outlining the zonal boundaries during microscopic examination of all slides at each level of section. PSA was measured by the Yang polyclonal assay. In the univariant regression analysis the correlation coefficients among serum PSA and transition zone, peripheral zone and central zone volumes were 0.934, 0.546 and 0.368, respectively, strongly suggesting that most PSA leakage from the prostate into the serum comes from the transition zone. The regression of serum PSA and transition zone volumes leads to a prediction of approximately 0.261 ng./ml. PSA per gm. benign prostatic hyperplasia (BPH) plus an intercept of 0.878, a number in keeping with our 1987 estimates of 0.3 ng./ml./gm. BPH. The volumes of the 3 zones appeared to be independent variables. Transition zone volume showed the greatest variation because of BPH. The mean average ratio of peripheral zone volume to central zone volume was nearly 3:1. These data strongly support the concept of age-adjusted PSA levels, since most of the increase in size of the prostate with increasing patient age comes from the transition zone from which BPH develops.

Prediction of prostate cancer volume using prostate-specific antigen levels, transrectal ultrasound, and systematic sextant biopsies

OBJECTIVES

Prostate-specific antigen (PSA) levels, transrectal ultrasound, and systematic sextant biopsies have each shown limited ability to predict prostate cancer volume. In combination, these studies may allow more accurate estimation of volume and prognosis.

METHODS

One hundred twenty-four patients were evaluated prior to radical prostatectomy. Interactive stepwise multiple regression and separate logistic regression analysis were performed for prediction of prostate cancer volume and volume range.

RESULTS

The cancer volumes calculated correlated with the volumes in the radical prostatectomy specimens with R2 of 0.76. Cancers were predicted to be in the volume range associated with poor prognosis (more than 12 cc) or clinically insignificant cancer (less than 1.0 cc) with bias corrected error rates of 5.3% and 10%, respectively.

CONCLUSIONS

The formula for prediction of cancer volume correlates well with actual cancer volume in 92 patients but is not adequate to predict volume for an individual patient. The formulas for prediction of volume range show promising predictive ability and may be useful if the extent of disease is unclear.

Clinical usefulness of free and complexed PSA

We selected serums from 51 fully characterized prostate cancer patients and 48 biopsy-proven BPH patients in order to test the ability of the ratio of the free/total PSA in distinguishing between CaP and BPH patients in the best case scenario. The 51 cancer patients had cancer volumes ranging from 2.0-17.8 mL and had a median % free PSA of 8.9%. The 48 BPH patients, which had prostate volumens ranging from 36.9-313.8 mL, had a median % free PSA of 16.5%, almost twice that of the CaP patients. We also examined the physiological variation of serums drawn on the same patient over a reasonably short time (mean of 22 days). The variation between consecutive redraws on the same patient was measured to be 30% (95% confidence interval) in the PSA range of 4-10 micrograms/L, measured on the Hybritech Tandem-R PSA Assay.

A universal calibrator for prostate specific antigen (PSA)

We describe for the first time a protocol to purify an in vitro made PSA-ACT complex to apparent homogeneity by using a combination of gel filtration and ion-exchange chromatography. The purity of the PSA-ACT complex was confirmed by gel electrophoresis and Western blot. Purification of the PSA-ACT complex was highly reproducible. An extinction coefficient of 1.0 and 280 nm (L x g-1 x cm-1) was assigned to the PSA-ACT complex based on amino acid analysis. Molecular weight was assigned by taking cDNA of ACT (plus 26% carbohydrate) and the molecular weight of PSA (28,430) which totals 89,280. Two common calibrators were made consisting of 100% PSA-ACT complex and/or 90% PSA-ACT complex plus 10% free PSA (90:10 calibrator). The 90:10 calibrator is recommended as a universal calibrator for the international standardization of PSA immunoassays.

[Long-term follow-up of serum prostate-specific antigen after radiotherapy of prostatic carcinoma]

The role of prostate-specific antigen (PSA) in the follow-up of patients after radiation therapy for prostate cancer is not well defined. There are no reports on long-term follow-up with PSA and serial PSA determinations, respectively. We followed 113 patients after radiotherapy for clinical stages A through D1 prostate cancer with multiple PSA measurements. External beam radiation has been applied to 98 patients and 15 received 125-iodine implantation. Eighty-eight of the 113 patients (78%) had a precipitously rising PSA with median doubling times of 14 (stage A), 15 (stage B), 7 (stage C), and 8 (Stage D1) months, respectively, at a mean follow-up of 5 years after radiotherapy. Twenty-three of the 113 patients (20%) appeared cured with a PSA of 1.7 ng/ml or less at a mean follow-up of 9 years. Two of the 113 patients (2%) continued to have a decreasing PSA 3 years after irradiation. Among the cured patients there was no relationship to clinical stage or histological grade. We conclude that about 20% of patients with clinical stages A-D1 prostate cancer can be cured by radiotherapy. They can be identified by a very low serum PSA level which seems to persist indefinitely. The remaining 80% who fail radiation therapy appear to have an accelerated growth rate suggesting tumor clonogen repopulation during radiotherapy.

A comparison of 4 ultrasensitive prostate specific antigen assays for early detection of residual cancer after radical prostatectomy

The Yang Pros-Check, Abbott IMx, Tosoh AIA-PACK PA and Nichols Institute reference laboratory prostate specific antigen (PSA) assays were compared in 30 patients (138 sera) known to have no residual prostate cells. The mean + 3 standard deviations of these sera was used to define a level of PSA that would indicate residual cancer. This residual cancer detection limit for each of the 4 assays is 0.06, 0.01, 0.07 and 0.05 ng./ml., respectively, but the 0.01 level for the IMx assay is an artifact caused by setting the zero calibrator too high. All 4 assays were then used to compare the number of days from radical prostatectomy to the detection of residual cancer in 23 cases (211 sera) that ultimately failed radical prostatectomy. The Yang, Tosoh and Nichols Institute assays were all similar, with an average of 569 to 589 days. The Abbott IMx assay was relatively insensitive in detecting the first appearance of PSA after radical prostatectomy (average 821 days) and it showed the earliest detection among the 4 assays in only 1 of 23 patients.

Serum prostate specific antigen binding alpha 1-antichymotrypsin: influence of cancer volume, location and therapeutic selection of resistant clones

We examined by gel filtration chromatography (Sephacryl 200) sera from 73 untreated patients with peripheral zone prostatic cancer volumes of 1 to 17 cc as well as patients with clinical stages C and D2 cancer. We also examined the sera from 40 patients who had failed radiation or hormonal therapy to determine if clonal cell selection by these 2 therapies altered the binding of prostate specific antigen (PSA) to alpha 1-antichymotrypsin. Finally, we compared sera from 10 patients with benign prostatic hyperplasia (BPH) and 14 with large transition zone-BPH cancer. Without exception, of the total serum PSA recognized by the Hybritech Tandem-R, Yang Pros-Check, Abbott IMx and Ciba Corning ACS assays, 88 to 98% were complexed with alpha 1-antichymotrypsin in all cancer patients. The 10 patients with BPH showed less complexation (73 to 84%). These studies suggest that much of the quantitative differences among assays is determined more by relative differences in recognition of the free and complex forms of PSA than by calibration differences between assays.

The pathological features and prognosis of prostate cancer detectable with current diagnostic tests

The discrepancy between the high prevalence of prostate cancer found at autopsy and the low incidence of clinical cancer prompted a study to determine whether the new diagnostic tests, that is ultrasonography and serum prostatic specific antigen (PSA) levels, detect prostate cancer at an earlier stage than the traditional test, digital rectal examination, without detecting a larger proportion of clinically unimportant cancer. Clinically detected cancer treated by radical prostatectomy (306 cases) and incidental cancer found in cystoprostatectomy specimens (90) were categorized into 3 groups by the volume, grade, extent of the cancer and outcome of treatment: clinically unimportant tumor (0.5 cm.3 or less, Gleason grades 1 to 3 and confined to the prostate), clinically important curable cancer (more than 0.5 cm.3 or grade 4 or 5 and confined, or with microscopic extracapsular extension) or advanced disease (extensive extracapsular extension, seminal vesicle invasion or lymph node metastases). Of 306 clinically detected tumors 9% were unimportant and 29% were advanced. In contrast, incidental cystoprostatectomy disease was either unimportant (78%) or curable (22%) and no tumor was advanced (p < 0.0005). Cancer detectable by digital rectal examination, ultrasonography or PSA was distributed similarly among the 3 groups. Impalpable cancer detected by PSA was less likely to be advanced (11%) than cancer detected by digital rectal examination (34%, p = 0.01) but no more likely to be unimportant (13% versus 8%). Of 29 tumors detected only by systematic biopsies because of an elevated PSA level only 4% were advanced, while 17% were unimportant. Cancer detectable with each of the available diagnostic tests was similar and differed distinctly from that found incidentally in cystoprostatectomy specimens. The detection of impalpable cancer by PSA or ultrasound decreased the proportion of advanced tumor detected without increasing significantly the detection of unimportant disease.

Prostate specific antigen as a predictor of an abnormal digital rectal examination

OBJECTIVE

To assess the ability of serum prostate specific antigen (PSA) to predict and differentiate patients with normal and abnormal digital rectal findings.

SUBJECTS AND METHODS

A prospective analysis of 1374 participants in a prostate cancer screening programme was performed. After completion of a questionnaire including age and voiding symptoms as well as phlebotomy for PSA analysis, digital rectal examination was performed and the findings were categorized with respect to size, consistency, symmetry and nodularity.

RESULTS

In men less than 50 years of age the mean serum PSA level failed to discriminate any of the digital rectal examination categories. In men over 50 there was a statistically significant difference in mean PSA levels between symmetrical, normal sized prostates and symmetrically enlarged glands as well as between symmetrical, normal sized and abnormal prostates (P < 0.05). No statistically significant difference was found in mean serum PSA levels between symmetrically enlarged prostate glands and those with palpable nodules. PSA levels < or = 2.5 ng/ml (normal range for the Yang polyclonal assay) and < 7.4 ng/ml (corresponding to the normal range of < 4.0 ng/ml for the Hybritech monoclonal assay) demonstrated a probability of an abnormal digital rectal examination of 11% and 14% respectively. PSA levels > 18.4 ng/ml (corresponding to monoclonal levels of > 10 ng/ml) had a 67% probability of an abnormal digital rectal examination. However, moderate elevations in PSA could not be used to predict digital examination abnormalities due to the high incidence of moderate PSA elevations associated with symmetrical enlargement of the prostate.

CONCLUSIONS

Serial annual PSA measurements may provide an alternative means of screening men over 50 years of age. Contamination of results with PSA elevation due to benign prostatic hyperplasia remains, however, a problem.

[Effect of the natural history on management of adenocarcinoma of the prostate]

The natural history of prostate cancer has long been regarded as unpredictable. The discrepancy between histologically identifiable (40%) and clinically diagnosed carcinomas (8%) led to the term of "latent" prostate cancer and to considerable diagnostic and therapeutic dilemmas. Based on our previous studies showing that biological aggressivity of prostate cancer is a direct function of tumor volume and that tumor volume and serum PSA are proportional, we evaluated two basically different groups of patients. The first group consisted of 43 patients with untreated carcinomas of the prostate followed with serial PSA determinations. The exponential (log-linear) rise in PSA led us to the conclusion of an exponential tumor growth rate. The median doubling time of clinically organ-confined tumors was 4 years and became shorter with higher clinical stages and poorly differentiated histological grades. The second group consisted of 139 patients who underwent cystoprostatectomy for bladder cancer and had no evidence for simultaneously identifiable prostate cancer. In 55 patients (40%), unsuspected prostate cancer was found in the specimen; the volume distribution of these carcinomas was exponential. These 139 men included 11 (7.9%) who had a prostate cancer with a volume greater than 0.5 cm3, corresponding to the 8% risk for a man being diagnosed within his lifetime with a clinically significant carcinoma of the prostate. We conclude that the other 44 carcinomas, which were less than 0.5 cm3 in volume, will never reach clinical significance because of their small size and their long doubling time; in this sense they can be considered latent.(ABSTRACT TRUNCATED AT 250 WORDS)

Antiproliferative effects of 1,25-dihydroxyvitamin D3 on primary cultures of human prostatic cells

Cultures of adult human prostatic epithelial and fibroblastic cells were established from normal, benign hyperplastic, and malignant tissues. Vitamin D receptors were detected by ligand binding of [3H]1,25-dihydroxyvitamin D3 [1,25(OH)2D3] in cytosolic extracts prepared from all types of cell cultures as well as from fresh prostatic tissues. Vitamin D receptor transcripts were demonstrated by Northern blot analysis. 1,25-(OH)2D3 inhibited the growth of epithelial cells with half-maximal inhibition at approximately 1 nM. The growth of fibroblasts was also inhibited by 1,25(OH)2D3 but to a lesser extent. This is consistent with the apparently lower level of vitamin D receptors in fibroblasts compared to epithelial cells determined by ligand binding and Northern analysis of RNA transcripts. The growth inhibition of epithelial cells by 1,25(OH)2D3 was irreversible even after a short 2-h exposure, but morphology and keratin expression were not appreciably altered by long-term exposure to the hormone. A physiological role for 1,25(OH)2D3 in the prostate is postulated, and the inhibitory effect of 1,25(OH)2D3 on cancer-derived prostate cells may provide a basis for new preventive or therapeutic strategies.

Utilization of polyclonal serum prostate specific antigen levels in screening for prostate cancer: a comparison with corresponding monoclonal values

OBJECTIVES

Prostate specific antigen (PSA) measurement has become increasingly popular as a screening test for prostatic adenocarcinoma. Although this is a sensitive, organ-specific assay, use as a screening tool is hampered by the lack of a clearly defined normal range in older men, frequent elevation of PSA levels by benign processes, and the availability of two different assays, one polyclonal and the other monoclonal, which produce very different values. This study was designed to evaluate the distribution of PSA levels by the Yang and corresponding Hybritech values in patients from the general population.

SUBJECTS AND METHODS

A total of 478 volunteers over 40 years of age underwent serum PSA determination by the Yang polyclonal radioimmunoassay and digital rectal examination. The PSA levels were stratified and the patient distribution analysed.

RESULTS

In 69% of patients, PSA levels were < or = 2.5 ng/ml (proposed normal range for the Yang polyclonal assay). In 89% of patients, PSA levels were < or = 7.3 ng/ml by the polyclonal assay which corresponds approximately to the proposed normal range of 0-4.0 ng/ml by the Hybritech monoclonal assay. Nine per cent of patients fell between 7.4 and 18.4 ng/ml by the polyclonal assay (4.1-10 ng/ml by the monoclonal assay) and 2% had polyclonal PSA levels > 18.4 ng/ml (> 10 ng/ml by the monoclonal assay). Cancer detection rates (influenced by the percentage of patients undergoing biopsy) were 0.3% in patients with polyclonal PSA levels < or = 2.5 ng/ml, 1.2% in patients < or = 7.3 ng/ml, 20.9% between 7.4 and 18.4 ng/ml, and 50% of those > 18.4 ng/ml; the overall cancer detection rate was 3.8%.

CONCLUSIONS

These data support the use of higher PSA levels as a criterion for further evaluation in screening for prostate cancer and establish the frequency distribution of PSA in a screening population when the Yang assay is used.

Youssef's syndrome: preservation of uterine function with subsequent successful pregnancy following surgical repair

We report a 30-year-old female with vesicouterine fistula (Youssef's syndrome). Surgical therapy included transabdominal repair of bladder and uterus with interposition of greater omentum. Uterine function was preserved with subsequent successful pregnancy and delivery of a healthy baby boy by elective Cesarean section at 36 weeks' gestation. The details of the case are discussed and the literature is reviewed regarding fertility and pregnancy after surgical repair.