Download Radical prostatectomy and lymphadenectomy in clinically locally

RADICAL PROSTATECTOMY
AND LYMPHADENECTOMY
IN CLINICALLY LOCALLY
ADVANCED PROSTATE
CANCER PATIENTS
Professor Guram Karazanashvili MD, KMSc, DMSc
MMT Hospital
When diagnosis of clinically
locally advanced prostate cancer
is established, patient selection
and preparation for the surgery is
critically important
Patient examination
• Experienced surgeon does DRE and TRUS
• DRE and TRUS are essential for
estimation of resectability:
Prostate consistence
Prostate apex
Lateral margins
Adherence to rectum
Seminal vesicles
Patient consultation
• How looks the patient?
• How motivated is he?
• Has the patient voiding problems?
• Take a time to explain the patient:
-Different treatment modalities in context of
quality of life and effectiveness
-Necessity in adjuvant treatments
-Speak with patient together with close relatives
-Give patient a time for consideration
Patient selection
 Good performance status
 10 year survival should be expected
 Patient motivated for aggressive cancer
management
 Patients ready for increased risk of
incontinence and impotence
Preoperative evaluation and
preparation
•
Standardized preparation of patients for the surgery reduces
the risks of intra and postoperative complications
•
Special team is advisable for routine preoperative check up:
Cardiologists, Anesthesiologist and urologist
•
Send the patient for coronarography in any doubtful case
•
Coronary stenting or bypass before surgery reduces the risks
•
Hospitalization 1 day before the surgery
•
Bowel preparation is needed, especially in locally advanced
cases
•
Anticoagulants night before surgery
•
Gloves before surgery
Patients
 Surgery from 2011 to 2014, by single
surgeon
 48 Patients with clinically locally
advanced Prostate cancer were selected
for the surgery
T3a - 21patients
T3b – 17 patients
T4 – 8 patients
Patients
• DRE detected extra capsular spread
• Extra capsular spread was confirmed by TRUS,
CT/MRI
• No balky lymph nodes by CT/MRI
• Bone scan was negative
• Patient age:
50-60 years – 6 cases
60-70 years – 21 cases
70-75 years – 19 cases
Preoperative data
 PSA < 30ng/ml
 Gl. 5-6




12 cases
Gl. 7 (3+4) 5 cases
Gl. 7 (4+3) 16 cases
Gl. 8
6 cases
Gl.9
3 cases
Tipe of Surgery
• Radical prostatectomy with extended
•
•
•
•
lymphadenectomy (along internal and external
iliac vessels) – 38 cases
Radical prostatectomy with bladder neck wide
excision, and extended lymphadenectomy (along
internal and external iliac vessels) – 4 cases
Radical cystoprostatectomy, extended
lymphadenectomy, sigma-rectum pouch – 1case
Radical cystoprostatectomy, extended
lymphadenectomy, ileal conduit (Briker’s
operation) - 3 cases
Monolateral or bilateral Nerve sparing – 24
cases
Surgical margins
 Surgical margins were positive in 15 (of 46)
patients:
Apex
3 cases
Neurovascular bundle 1 case
Bladder neck
7 case
Other locations
4 case
 Relatively high incidence of positive margins at
bladder neck was determined by preoperative
downstaging and absence of macroscopic
alterations intraoperatively
Stage migration
• Preoperative T stage migration occurred in
39% of cases:
Downstaging
14 cases
Overstaging 5 cases
• Preoperative N stage migration occurred in
43% of cases:
Downstaging 20 cases
Stage migration
• In 7 (of 12) downstaged men local spread
reached T4 stage. These men need wide
excision of bladder neck, beyond
macroscopic alterations.
• 3 (of 5) T overstaged cases were node free.
Thus surgery was curative
• 20 N downstaged men might benefit from
lymphadenectomy
PSA > 0.2ng/ml at 3 monthes
N+ and positive surgical margins
5 cases
N+
4 cases
Positive surgical margins
2 cases
N- and negative surgical margins
2 cases
Overall in 28% of cases PSA>0.2ng/ml at 3
months, most of these patients are N+.
 Only 7 (of 15) patients with positive surgical
margins had PSA nadir above 0.2ng/ml. Thus
despite residual tumor, prognosis can be
favorable





Adjuvant therapies
 Antiandrogens
4
cases
 Medical or surgical castration
4
cases
 Radiation therapy+medical castration 3
cases
 No adjuvant therapies
35
cases
76% of patients with
clinically locally advanced
cases have got no adjuvant
therapies!
Bone metastasis
Currently 0 (of 46) patients
have bone metastasis after
surgery for clinically locally
advanced prostate cancer
Incontinence
• At 3 monthes:
Total incontinence
Stress incontinence
Continent
• Currently:
Total incontinence
Stress incontinence
Continent
0 of (42) cases
12 (of 42) cases
30 (of 42) cases
0 (of 42) cases
4 (of 42) cases
38 (of 42) cases
Conclusions
 Radical surgery is feasible in men with
clinically locally advanced prostate cancer
and should be applied in selected patients
 Significant number of patients can be
saved from adjuvant therapies
 Surgical excision has potential to delay
development of bone metastasis
 Functional outcomes are excellent
Conclusions
• Node status downstaging, is common in
cases of clinically locally advance prostate
cancer patients
• Extended lymphadenectomy is
recommended in all cases, this might have
therapeutic results
• Bladder neck invasion is not rare, wide
excision of bladder neck is recommended,
even in case of absence of macroscopic
alterations