Download Surgical Management of Prostate Cancer

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.