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Surgical Management of Prostate Cancer XXII Urologic Oncology Conference Portugal J.Edson Pontes M.D. The Inability to Predict Response to Therapy as a consequence of unpredictable Tumor Biology provides an Argument for Surgical Excision since the “CURE” of an excised Tumor is independent of its responsiveness to alternatives Therapies Whitmore,W. Urol.Clin NA 1984 Radical Retropubic Prostatectomy • Is the most utilized surgical approach • Understanding of the Anatomy has decreased intraoperative complications and surgical time. • Pain control has decreased LOS and cost Indications for open radical prostatectomy • Complications during robotic surgery: respiratory, vascular, iatrogenic rectal injury. • Salvage Procedures? • Morbid obesity AVERAGE LOS BEFORE and AFTER CCP 8 7 6 5 LOS 4 3 2 1 0 1990-94 1994-96 COMPLICATION RATES BEFORE and AFTER CCP BEFORE % PATIENTS 607 AFTER % 522 MAJOR 8.5 % MINOR 12% 9% READMISSION 2% 3% MORTALITY 0.5% 5.9% 0% Pathological Stage OC EPE M(-) SM EPE M(+) SV LN VARIABILITY AMONG SURGEON’S ON CANCER CONTROL AFTER RADICAL PROSTATECTOMY Bianco FJ.1AD, Vickers A.12A, Serio A.12A, Eastham JA.1A, Kline EA.1A, Reuther A.1B, Kattan MW.3B, Pontes JE.1C, Scardino PT.1A Departments of Urology1, Biostatistics2 and Quantitative Health Sciences3 Memorial Sloan-Kettering Cancer Center.A Cleveland Clinic Foundation.B Wayne State University.C George Washington University.D CANCER CONTROL 5 YEARS AFTER RP Patients at Risk 6828 6390 5861 5318 4776 4279 3810 3447 3053 2713 0.8 0.7 0.6 Freedom from BCR 0.9 1.0 7765 7849 0 6 12 18 24 30 36 42 Time (months) after Radical Prostatectomy 48 54 60 5-YR BCR-FREE PROBABILITIES BY SURGEON EXPERIENCE Vickers & Bianco et al. JNCI (2008) VARIATION AMONG SURGEONS – Significant heterogeneity in BCR rates was observed between surgeons (p<0.01) – I2 = 0.38, implies that 38% of the observed difference in BCR rates between surgeons can be explained by genuine differences in surgical technique and approach, rather than by chance alone Parameters of Comparison between different techniques • Positive Surgical Margins( M+) • Continence • Potency • Complications • Cancer Control How Surgeons are trained • In open radical prostatectomy, the surgical skills are the same as for other open procedures. The number of cases, and “Hands” will determine how good you perform the operation. Since surgical skills are very individual, learning curves are variable and the results among surgeons different. How Surgeons are trained • In Laparoscopic Radical Prostatectomy, new surgical skills are needed. There is a long learning curve, and you still need “Hands” How Surgeons are Trained • In Robotic Assisted Laparoscopic Radical Prostatectomy, new surgical skills are needed, there is a shorter learning curve and “Hands” are less important. And this is a good thing! It may equalize surgeons. Risk- Adjusted Analysis of positive surgical Margins Following Laparoscopic and Retropubic Radical Prostatectomy. Touijer, K. et al. Eur. Urol. 2007 No difference in PSM rates among the 2 procedures. Retropubic, Laparoscopic, and Robot-Assisted radical prostatectomy: A systematic Review and cumulative Analysis of Comparative Studies. Ficarra, V. et al Eur.Urol 2009 Surgery and Marketing: comparing different methods of radical prostatectomy. • “available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncological outcomes”. • What matters is that surgery is done by an expert.. Marketing and the generation of myths surrounding different techniques have obscured this fundamental truth • Wirth, M. and Hakenberg Eur. Urol. 2009 CONCLUSIONS • Radical Prostatectomy is an excellent option for the treatment of localized prostate cancer. • At the present there is no difference in outcome among patients treated with open, LAP or RALP. • Urologists however should use these new techniques as Tools to facilitate their surgical skills.